Healthcare Provider Details

I. General information

NPI: 1639126253
Provider Name (Legal Business Name): WILLIAM KURT WILKENING O. D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/28/2006
Last Update Date: 06/30/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

935 ROYAL AVE
MEDFORD OR
97504-6140
US

IV. Provider business mailing address

935 ROYAL AVE
MEDFORD OR
97504-6140
US

V. Phone/Fax

Practice location:
  • Phone: 541-779-2211
  • Fax: 541-779-8778
Mailing address:
  • Phone: 541-779-2211
  • Fax: 541-779-8778

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1569ATI
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: