Provider Demographics
NPI:1386958726
Name:WILDER, TRAVIS JORDAN (MD)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:JORDAN
Last Name:WILDER
Suffix:
Gender:
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:PO BOX 733784
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75373-3784
Mailing Address - Country:US
Mailing Address - Phone:682-885-6483
Mailing Address - Fax:682-885-3113
Practice Address - Street 1:1500 COOPER ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-2710
Practice Address - Country:US
Practice Address - Phone:682-885-6400
Practice Address - Fax:682-885-6101
Is Sole Proprietor?:No
Enumeration Date:2010-07-27
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102742483-1205208G00000X
TXS2539208G00000X
390200000X
OH35.142443208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program