Healthcare Provider Details

I. General information

NPI: 1154360824
Provider Name (Legal Business Name): JOHN ELGIN WILKAITIS M.D.,M.B.A., M.S.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2006
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 INTERSTATE 55 FRONTAGE ROAD N SUITE 234
JACKSON MS
39211-5931
US

IV. Provider business mailing address

70 GRANDVIEW CIR
BRANDON MS
39047-7398
US

V. Phone/Fax

Practice location:
  • Phone: 601-982-8531
  • Fax: 888-735-7202
Mailing address:
  • Phone: 601-829-4170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number17435
License Number StateMS
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2005021711
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number17435
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: