Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207PE0004X | Emergency Medical Services | 4301063412 | MI |
NPI | 1023114287 |
---|---|
Provider Name | Dr. Mark D. Wilkerson |
First Address | Flint, MI 48503-5902 |
Second Address | Flint, MI 48503-5902 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 15/09/2006 |
Last Update Date | 17/07/2014 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
0B51090 | BLUE SHIELD (01) | MI |
3423682 | (05) | MI |
G51320 | (02) | MI |