Healthcare Provider Details

I. General information

NPI: 1376519488
Provider Name (Legal Business Name): RICHARD JEROME WILKERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/28/2006
Last Update Date: 04/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

IV. Provider business mailing address

502 ELM ST NE
ALBUQUERQUE NM
87102-2512
US

V. Phone/Fax

Practice location:
  • Phone: 505-841-1000
  • Fax: 505-843-2592
Mailing address:
  • Phone: 505-841-1000
  • Fax: 505-843-2956

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberD0062101
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberK9455
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License NumberMD2014-0991
License Number StateNM

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: