Provider Demographics
NPI:1033111836
Name:WILKES, DONNELLY
Entity Type:Individual
Prefix:
First Name:DONNELLY
Middle Name:
Last Name:WILKES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 S REINO RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-4284
Mailing Address - Country:US
Mailing Address - Phone:805-499-4446
Mailing Address - Fax:805-499-3636
Practice Address - Street 1:400 S REINO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-4284
Practice Address - Country:US
Practice Address - Phone:805-499-4446
Practice Address - Fax:805-499-3636
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85368207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABY173AMedicare PIN