Provider Demographics
NPI:1548397821
Name:WILDER, DEREK L (OD)
Entity type:Individual
Prefix:DR
First Name:DEREK
Middle Name:L
Last Name:WILDER
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4000 POPLAR LEVEL RD
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40213-1524
Mailing Address - Country:US
Mailing Address - Phone:502-813-8923
Mailing Address - Fax:502-451-8663
Practice Address - Street 1:11310 BEACH CHANNEL DR
Practice Address - Street 2:
Practice Address - City:ROCKAWAY PARK
Practice Address - State:NY
Practice Address - Zip Code:11694-2209
Practice Address - Country:US
Practice Address - Phone:718-474-1234
Practice Address - Fax:718-945-5809
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY1704DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000545218OtherANTHEM BCBS
KY1704DTOtherOD LICENSE NUMBER
KY000000538129OtherANTHEM BCBS
KYP00714374OtherRR MEDICARE
KY7100018030Medicaid
KY5419240005Medicare NSC
KY5419240011Medicare NSC
KY000000538129OtherANTHEM BCBS