Basic Information
| Provider Information | |||||||||
| NPI: | 1730147232 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILDERMAN | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | ANTHONY | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | PT DPT MS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CENTURIAN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026335787 | ||||||||
| FaxNumber: | 3026335781 | ||||||||
| Practice Location | |||||||||
| Address1: | 1 CENTURIAN DR | ||||||||
| Address2: | SUITE 110 | ||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026335787 | ||||||||
| FaxNumber: | 3026335781 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 06/19/2014 | ||||||||
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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 | 225100000X | PT006145L | PA | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | J1-0002854 | DE | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.