Healthcare Provider Details

I. General information

NPI: 1609839117
Provider Name (Legal Business Name): BRUCE WILKERSON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 04/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1305 CROWLEY RAYNE HWY
CROWLEY LA
70526-8202
US

IV. Provider business mailing address

8124 WALDEN RD
BATON ROUGE LA
70808-5945
US

V. Phone/Fax

Practice location:
  • Phone: 800-893-9698
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number019768
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: