Provider Demographics
NPI:1023114287
Name:WILKERSON, MARK D (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:D
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1 HURLEY PLZ
Mailing Address - Street 2:5TH FLOOR S.O.N.
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48503-5902
Mailing Address - Country:US
Mailing Address - Phone:810-262-9353
Mailing Address - Fax:810-760-0440
Practice Address - Street 1:1 HURLEY PLZ
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48503-5902
Practice Address - Country:US
Practice Address - Phone:810-262-9429
Practice Address - Fax:810-262-9229
Is Sole Proprietor?:No
Enumeration Date:2006-09-15
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301063412207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3423682Medicaid
MI0B51090OtherBLUE SHIELD
MIMI6835Medicare PIN
MI0M54610001Medicare ID - Type Unspecified
MI3423682Medicaid