MEDICARE: MR. STEPHEN MARK WILKES OD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	3238TG	TX

General Provider Information

NPI Number	:	1255317202
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. STEPHEN MARK WILKES OD

Provider Business Mailing Address
First Line	:	2002 MERRIMAC TRL
Second Line	:
City	:	GARLAND
State	:	TX
Zip	:	75043-1235
Country	:	US
Telephone Number	:	972-840-0822
Fax Number	:	214-388-4753

Provider Business Practice Location Address
First Line	:	2744 S BUCKNER BLVD
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75227-6903
Country	:	US
Telephone Number	:	214-388-9767
Fax Number	:	214-388-4753

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/21/2005
Last Update Date	:	07/08/2007

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