Healthcare Provider Details

I. General information

NPI: 1841287414
Provider Name (Legal Business Name): KENNETH R WILHELM DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/29/2005
Last Update Date: 11/29/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6101 REDWOOD SQUARE CTR SUITE 303
CENTREVILLE VA
20121-4265
US

IV. Provider business mailing address

6101 REDWOOD SQUARE CTR SUITE 303
CENTREVILLE VA
20121-4265
US

V. Phone/Fax

Practice location:
  • Phone: 703-996-3000
  • Fax: 703-229-1152
Mailing address:
  • Phone: 703-996-3000
  • Fax: 703-229-1152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License Number0103000986
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: