Healthcare Provider Details

I. General information

NPI: 1992063879
Provider Name (Legal Business Name): GAVIN RAY WILKS M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2012
Last Update Date: 06/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

701 UNIVERSITY BLVD E STE 604
TUSCALOOSA AL
35401-7411
US

IV. Provider business mailing address

518 COUNTY ROAD 154
CROSSVILLE AL
35962-4217
US

V. Phone/Fax

Practice location:
  • Phone: 205-759-6925
  • Fax: 205-759-6926
Mailing address:
  • Phone: 256-572-0812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number38426
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: