Provider Demographics
NPI:1407877038
Name:WILDEMAN, CHRISTINE LYNN (MD)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:LYNN
Last Name:WILDEMAN
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 1:2830 BEE RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34239-7115
Mailing Address - Country:US
Mailing Address - Phone:941-927-1234
Mailing Address - Fax:941-921-0043
Practice Address - Street 1:2830 BEE RIDGE RD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34239-7115
Practice Address - Country:US
Practice Address - Phone:941-927-1234
Practice Address - Fax:941-921-0043
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2025-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA057705207Q00000X
FLME143999207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49553054Medicaid
G56225Medicare UPIN
COC811299Medicare PIN