Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207KA0200X | Allergist | 081878 | NY |
NPI | 1619961539 |
---|---|
Provider Name | Dr. Jerome Wildes |
First Address | Lawrence, NY 11559-1502 |
Second Address | Howard Beach, NY 11414-3126 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/09/2005 |
Last Update Date | 05/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
C05666 | (02) |