Provider Demographics
NPI:1396062287
Name:WILDER, VENIS TIARRA (MD)
Entity type:Individual
Prefix:MS
First Name:VENIS
Middle Name:TIARRA
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8400 NW 33RD ST STE 201
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33122-1937
Mailing Address - Country:US
Mailing Address - Phone:786-408-8502
Mailing Address - Fax:
Practice Address - Street 1:180 SW 84TH AVE
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2731
Practice Address - Country:US
Practice Address - Phone:954-945-3510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-30
Last Update Date:2019-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY263649207Q00000X
FL139734207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03716332Medicaid
NY03716332Medicaid