1316006539 NPI number — G JASON WILKS DPM

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316006539 NPI number — G JASON WILKS DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKS
Provider First Name:
G
Provider Middle Name:
JASON
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DPM
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WILKS
Provider Other First Name:
GORDON
Provider Other Middle Name:
JASON
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
DPM
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1316006539
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/12/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2579 NW EDENBOWER BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROSEBURG
Provider Business Mailing Address State Name:
OR
Provider Business Mailing Address Postal Code:
97471-6220
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-673-0742
Provider Business Mailing Address Fax Number:
541-673-7553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1813 W HARVARD AVE STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROSEBURG
Provider Business Practice Location Address State Name:
OR
Provider Business Practice Location Address Postal Code:
97471-2754
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
541-673-0742
Provider Business Practice Location Address Fax Number:
541-673-7553
Provider Enumeration Date:
12/06/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  DP00318 , registered in the state of OR ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 067946000 . This is a "REGENCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 7600580001 . This is a "PTAN DME" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: DX4938 . This is a "RR MDC GROUP PTAN" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 500720262 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 430895102 . This is a "REGENCE BC HMO" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: 480028890 . This is a "RR MEDICARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: R192914 . This is a "PTAN MEDICARE ORGANIZATION" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".
  • Identifier: D201111 . This is a "PACIFIC SOURCE" identifier , issued by the state of ( OR ) . This identifiers is of the category "OTHER".




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