1689777468 NPI number — LEONARD WILKINS O.D.

Table of content: LEONARD WILKINS O.D. (NPI 1689777468)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689777468 NPI number — LEONARD WILKINS O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILKINS
Provider First Name:
LEONARD
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
O.D.
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:
1689777468
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/14/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
209 WOODLAWN AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TAHLEQUAH
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
74464-3317
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
918-456-0585
Provider Business Mailing Address Fax Number:
918-456-6232

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
209 WOODLAWN AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TAHLEQUAH
Provider Business Practice Location Address State Name:
OK
Provider Business Practice Location Address Postal Code:
74464-3317
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
918-456-0585
Provider Business Practice Location Address Fax Number:
918-456-6232
Provider Enumeration Date:
09/06/2006

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: 152WC0802X , with the licence number:  815 , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0676100001 . This is a "DMERC/PIN" identifier . This identifiers is of the category "OTHER".
  • Identifier: 156833 . This is a "FED NWO" identifier . This identifiers is of the category "OTHER".
  • Identifier: 100767470A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5001 . This is a "NEFN DISP" identifier . This identifiers is of the category "OTHER".
  • Identifier: 900243 . This is a "OK. NWO" identifier , issued by the state of ( OK ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com