1487745683 NPI number — CRAIG WILDER MD

Table of content: CRAIG WILDER MD (NPI 1487745683)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1487745683 NPI number — CRAIG WILDER MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILDER
Provider First Name:
CRAIG
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1487745683
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/27/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2024 GEORGIA AVE NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
DC
Provider Business Mailing Address Postal Code:
20001-3027
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
202-865-3415
Provider Business Mailing Address Fax Number:
202-865-6876

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2510 MOORES PLAINS BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
UPPER MARLBORO
Provider Business Practice Location Address State Name:
MD
Provider Business Practice Location Address Postal Code:
20774-8027
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
202-865-1121
Provider Business Practice Location Address Fax Number:
202-865-4492
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207P00000X , with the licence number:  MD34904 , registered in the state of DC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010119561 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 406528000 , issued by the state of ( MD ) . This identifiers is of the category "MEDICAID".




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