Provider Demographics
NPI:1326910688
Name:WILDES, MARK JOSEPH
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:JOSEPH
Last Name:WILDES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 WILSON ST
Mailing Address - Street 2:
Mailing Address - City:STRUTHERS
Mailing Address - State:OH
Mailing Address - Zip Code:44471-1640
Mailing Address - Country:US
Mailing Address - Phone:330-531-2175
Mailing Address - Fax:
Practice Address - Street 1:940 WINDHAM CT STE 8
Practice Address - Street 2:
Practice Address - City:YOUNGSTOWN
Practice Address - State:OH
Practice Address - Zip Code:44512-5060
Practice Address - Country:US
Practice Address - Phone:330-720-9676
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-09-18
Last Update Date:2025-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHLD.09745133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered