Healthcare Provider Details

I. General information

NPI: 1407847668
Provider Name (Legal Business Name): MICHAEL DEE WILKERSON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2005
Last Update Date: 01/31/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MEDI PARK DR
AMARILLO TX
79106-2104
US

IV. Provider business mailing address

1452 N FREEDOM ROAD CT
WICHITA KS
67230-7219
US

V. Phone/Fax

Practice location:
  • Phone: 806-355-9447
  • Fax: 806-356-9251
Mailing address:
  • Phone: 806-355-9447
  • Fax: 806-356-9251

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberF9067
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: