Provider Demographics
NPI:1144899055
Name:WILDER, ELIJAH FORREST (MD)
Entity type:Individual
Prefix:
First Name:ELIJAH
Middle Name:FORREST
Last Name:WILDER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1 HOSPITAL DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65212-1000
Mailing Address - Country:US
Mailing Address - Phone:573-882-8907
Mailing Address - Fax:573-884-1070
Practice Address - Street 1:1 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-1000
Practice Address - Country:US
Practice Address - Phone:573-882-8907
Practice Address - Fax:573-884-1070
Is Sole Proprietor?:No
Enumeration Date:2021-06-24
Last Update Date:2021-06-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MO20210241682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry