Healthcare Provider Details

I. General information

NPI: 1639293798
Provider Name (Legal Business Name): DOUGLAS CLIFTON WILKERSON M. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 E WACKER DR SUITE 630
CHICAGO IL
60601-1802
US

IV. Provider business mailing address

1 E WACKER DR SUITE 630
CHICAGO IL
60601-1802
US

V. Phone/Fax

Practice location:
  • Phone: 312-755-0643
  • Fax: 773-538-8278
Mailing address:
  • Phone: 312-755-0643
  • Fax: 773-538-8278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0814X
TaxonomyPsychoanalysis Psychologist
License Number
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: