Healthcare Provider Details

I. General information

NPI: 1275678872
Provider Name (Legal Business Name): REBECCA LEE WILKS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/21/2007
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6206 W BELL RD #2
GLENDALE AZ
85308
US

IV. Provider business mailing address

6206 W BELL RD #2
GLENDALE AZ
85308
US

V. Phone/Fax

Practice location:
  • Phone: 623-694-6575
  • Fax:
Mailing address:
  • Phone: 623-694-6575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number20742
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code175L00000X
TaxonomyHomeopath
License Number0160
License Number StateAZ
# 3
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number20742
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: