Provider Demographics
NPI:1023071347
Name:WILKES, JOHN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:WILKES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MEDICAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385
Mailing Address - Country:US
Mailing Address - Phone:636-327-1202
Mailing Address - Fax:636-327-1222
Practice Address - Street 1:400 MEDICAL PLZ
Practice Address - Street 2:SUITE 100
Practice Address - City:LAKE ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63367-1490
Practice Address - Country:US
Practice Address - Phone:636-639-8600
Practice Address - Fax:636-639-8676
Is Sole Proprietor?:No
Enumeration Date:2006-04-08
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR7J99207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO208002113Medicaid
57015OtherGHP
273988OtherHEALTHLINK
4676254OtherAETNA
MI6198OtherBCBS
6198OtherBC
3609028OtherUHC
900002001OtherRR MEDICARE
MO000094020Medicare ID - Type Unspecified
3609028OtherUHC
900002001OtherRR MEDICARE