Basic Information
| Provider Information | |||||||||
| NPI: | 1396168753 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILDER | ||||||||
| FirstName: | AMETHYST | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1107 E 66TH ST | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314045701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9123508404 | ||||||||
| FaxNumber: | 9123508067 | ||||||||
| Practice Location | |||||||||
| Address1: | 5 MALL ANX | ||||||||
| Address2: | |||||||||
| City: | SAVANNAH | ||||||||
| State: | GA | ||||||||
| PostalCode: | 314064738 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9127218882 | ||||||||
| FaxNumber: | 8032818882 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/21/2014 | ||||||||
| LastUpdateDate: | 05/03/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/03/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 078341 | GA | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.