Basic Information
| Provider Information | |||||||||
| NPI: | 1285697656 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | DIAZ-CALDERON | ||||||||
| FirstName: | WILDER | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 961205 | ||||||||
| Address2: | |||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761611205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8177408400 | ||||||||
| FaxNumber: | 8177408516 | ||||||||
| Practice Location | |||||||||
| Address1: | 2821 LACKLAND ROAD | ||||||||
| Address2: | SUITE 216 | ||||||||
| City: | FORT WORTH | ||||||||
| State: | TX | ||||||||
| PostalCode: | 761164193 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8173783640 | ||||||||
| FaxNumber: | 8177408516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2006 | ||||||||
| LastUpdateDate: | 09/30/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | M5130 | TX | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00771456 | 01 | TX | RAILROAD MEDICARE | OTHER | 187347302 | 05 | TX | MEDICAID |