MEDICARE: DR. ALBERT H WILKINSON III MD

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	207Y00000X	Otolaryngology Physician	ME0056965	FL
2	207YS0123X	Facial Plastic Surgery Physician	ME0056965	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09996	OTHER	FL	BCBS

General Provider Information

NPI Number	:	1609878313
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. ALBERT H WILKINSON III MD

Provider Business Mailing Address
First Line	:	14546 SAINT AUGUSTINE RD
Second Line	:	SUITE 401
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5468
Country	:	US
Telephone Number	:	904-268-5366
Fax Number	:	904-268-5457

Provider Business Practice Location Address
First Line	:	14546 SAINT AUGUSTINE RD
Second Line	:	SUITE 401
City	:	JACKSONVILLE
State	:	FL
Zip	:	32258-5468
Country	:	US
Telephone Number	:	904-268-5366
Fax Number	:	904-268-5457

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

Provider Enumeration Date	:	08/12/2005
Last Update Date	:	08/13/2011

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