Provider Demographics
NPI:1861609521
Name:WILDER, KATHLEEN JENNIFER (MD MHS)
Entity type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:JENNIFER
Last Name:WILDER
Suffix:
Gender:F
Credentials:MD MHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3181 SW SAM JACKSON PARK RD
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-3011
Mailing Address - Country:US
Mailing Address - Phone:503-494-9000
Mailing Address - Fax:503-494-2391
Practice Address - Street 1:3181 SW SAM JACKSON PARK RD
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-3011
Practice Address - Country:US
Practice Address - Phone:503-494-9000
Practice Address - Fax:503-494-2391
Is Sole Proprietor?:No
Enumeration Date:2007-05-16
Last Update Date:2011-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD25779207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO68171731Medicaid
NM71557270Medicaid
AZ256334Medicaid
CO68171731Medicaid