Provider Demographics
NPI:1528082443
Name:WILT, STEPHEN R (MD, PHD)
Entity type:Individual
Prefix:DR
First Name:STEPHEN
Middle Name:R
Last Name:WILT
Suffix:
Gender:M
Credentials:MD, PHD
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Mailing Address - Street 1:4809 AMBASSADOR CAFFERY PKWY
Mailing Address - Street 2:STE 100
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70508-8800
Mailing Address - Country:US
Mailing Address - Phone:337-769-8660
Mailing Address - Fax:337-769-8661
Practice Address - Street 1:4809 AMBASSADOR CAFFERY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70508-8800
Practice Address - Country:US
Practice Address - Phone:337-769-8660
Practice Address - Fax:337-769-8661
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2020-06-29
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Provider Licenses
StateLicense IDTaxonomies
LA10351R2085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA10351ROtherSTATE MEDICAL LICENSE
LA1986739Medicaid
LAPTAN 381631ZLACOtherLINKED TO GROUP PTAN 381439 EFFECTIVE 10-31-14
LA5DX68OtherONCOLOGICS LLC GROUP PTAN MEDICARE EFFECTIVE 05/19/2012
LA5U307DX68OtherSTEPHEN WILT PTAN MEDICARE EFFECTIVE 05/19/2012
LA1986739Medicaid