Provider Demographics
NPI:1093788184
Name:WILKES, ROBERT MURRAY (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:MURRAY
Last Name:WILKES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BOUNTIFUL
Mailing Address - State:UT
Mailing Address - Zip Code:84010
Mailing Address - Country:US
Mailing Address - Phone:801-295-2020
Mailing Address - Fax:801-292-5575
Practice Address - Street 1:140 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BOUNTIFUL
Practice Address - State:UT
Practice Address - Zip Code:84010
Practice Address - Country:US
Practice Address - Phone:801-295-2020
Practice Address - Fax:801-292-5575
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-09
Last Update Date:2011-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT3581459934152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT870635456009Medicaid
U67567Medicare UPIN
UT005592301Medicare ID - Type Unspecified