1366425944 NPI number — DALERIE A. WILKERSON DPM

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366425944 NPI number — DALERIE A. WILKERSON DPM

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

WILKERSON

Provider First Name:

DALERIE

Provider Middle Name:

A.

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

DPM

Provider Gender Code:

F

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1366425944

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

12/04/2012

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 660599

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75266-0599

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

303 E OVERTON RD

Provider Second Line Business Practice Location Address:

BLUITT-FLOWERS HEALTH CENTER

Provider Business Practice Location Address City Name:

DALLAS

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75216-5946

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

214-266-4200

Provider Business Practice Location Address Fax Number:

214-266-4218

Provider Enumeration Date:

11/28/2005

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 213E00000X , with the licence number:  1527 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 143872311 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872306 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872309 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872312 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 8W8850 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 143872302 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872305 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872314 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872307 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872304 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872308 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872310 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 143872313 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".