Provider Demographics
NPI:1386056992
Name:WILDER, ERIC L (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:L
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1514 JEFFERSON HWY
Mailing Address - Street 2:
Mailing Address - City:NEW ORLEANS
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2429
Mailing Address - Country:US
Mailing Address - Phone:504-842-4000
Mailing Address - Fax:
Practice Address - Street 1:1401 JEFFERSON HWY
Practice Address - Street 2:
Practice Address - City:NEW ORLEANS
Practice Address - State:LA
Practice Address - Zip Code:70121-2426
Practice Address - Country:US
Practice Address - Phone:504-842-4747
Practice Address - Fax:504-842-3327
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-30
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2017-00843207Q00000X
NC201679207Q00000X
LA333104207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC201679OtherRTL
NC2017-00843OtherMEDICAL LICENSE
NCACS5385578-R130OtherDEA