Provider Demographics
NPI:1922019355
Name:WILDER, JASON EDWARD (R, MR)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:EDWARD
Last Name:WILDER
Suffix:
Gender:M
Credentials:R, MR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4921 WESLEYAN CIR
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2222
Mailing Address - Country:US
Mailing Address - Phone:478-477-8969
Mailing Address - Fax:
Practice Address - Street 1:1504 HARDEMAN AVE
Practice Address - Street 2:SUITE B
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1416
Practice Address - Country:US
Practice Address - Phone:478-745-3135
Practice Address - Fax:478-745-3136
Is Sole Proprietor?:No
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
330869247100000X, 2471C3402X, 2471M1202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Not Answered2471C3402XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistRadiography
Not Answered2471M1202XTechnologists, Technicians & Other Technical Service ProvidersRadiologic TechnologistMagnetic Resonance Imaging