Healthcare Provider Details

I. General information

NPI: 1568621803
Provider Name (Legal Business Name): JOHN BENJAMIN WILKINSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 01/09/2020
Certification Date: 01/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1213 E OCEAN AVE STE 100
LOMPOC CA
93436-7043
US

IV. Provider business mailing address

1213 E OCEAN AVE STE 100
LOMPOC CA
93436-7043
US

V. Phone/Fax

Practice location:
  • Phone: 57-368-6288
  • Fax: 805-736-8785
Mailing address:
  • Phone: 57-368-6288
  • Fax: 805-736-8785

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number55116
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberMD.206016
License Number StateLA
# 3
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberC156310
License Number StateCA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: