Provider Demographics
NPI:1083020622
Name:WILKINSON, MARK FORD (DO)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:FORD
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 E 10TH AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84103-2869
Mailing Address - Country:US
Mailing Address - Phone:801-831-5127
Mailing Address - Fax:
Practice Address - Street 1:324 E 10TH AVE STE 200
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84103-2869
Practice Address - Country:US
Practice Address - Phone:801-408-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-03
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT11318316-1204208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery