1497044291 NPI number — DUSTIN VAN WILKES DO

Table of content: DUSTIN VAN WILKES DO (NPI 1497044291)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497044291 NPI number — DUSTIN VAN WILKES DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKES
Provider First Name:
DUSTIN
Provider Middle Name:
VAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
Provider Gender Code:
M

Provider's Other Name Information

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 Information

NPI Number:
1497044291
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5310 HARVEST HILL RD STE 290
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:
75230-5826
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
214-420-0672
Provider Business Mailing Address Fax Number:
214-736-0512

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1709 MARTIN DRIVE
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
WEATHERFORD
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76086
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-594-5880
Provider Business Practice Location Address Fax Number:
806-977-9112
Provider Enumeration Date:
04/01/2011

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: 207N00000X , with the licence number:  P9487 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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