Healthcare Provider Details

I. General information

NPI: 1184604910
Provider Name (Legal Business Name): DONALD L. WILHELM M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/18/2006
Last Update Date: 10/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 BAGNELL DAM BLVD
LAKE OZARK MO
65049-8603
US

IV. Provider business mailing address

PO BOX 104240
JEFFERSON CITY MO
65110-4240
US

V. Phone/Fax

Practice location:
  • Phone: 573-635-5264
  • Fax: 573-556-5757
Mailing address:
  • Phone: 573-556-5191
  • Fax: 573-556-5757

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number118054
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License Number118054
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: