Provider Demographics
NPI:1174513915
Name:WILDER, DEBRA L (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:L
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 370
Mailing Address - Street 2:91 CEDAR STREET
Mailing Address - City:KUTTAWA
Mailing Address - State:KY
Mailing Address - Zip Code:42055-0370
Mailing Address - Country:US
Mailing Address - Phone:270-388-7380
Mailing Address - Fax:270-388-7364
Practice Address - Street 1:91 CEDAR ST
Practice Address - Street 2:
Practice Address - City:KUTTAWA
Practice Address - State:KY
Practice Address - Zip Code:42055-6287
Practice Address - Country:US
Practice Address - Phone:270-388-7380
Practice Address - Fax:270-388-7364
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY28168207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64281686Medicaid
KYP400031075Medicare PIN
KY64281686Medicaid