Healthcare Provider Details

I. General information

NPI: 1679754642
Provider Name (Legal Business Name): JULIA BLAIZE WILKINSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 01/16/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25 N. WINFIELD RD. STE 103
WINFIELD IL
60190
US

IV. Provider business mailing address

25 N. WINFIELD RD. STE 103
WINFIELD IL
60190
US

V. Phone/Fax

Practice location:
  • Phone: 630-933-4487
  • Fax: 630-933-2009
Mailing address:
  • Phone: 630-933-4487
  • Fax: 630-933-2009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number036135153
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number036135153
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: