Provider Demographics
NPI:1104186899
Name:WILKE, RYAN M (DO)
Entity Type:Individual
Prefix:
First Name:RYAN
Middle Name:M
Last Name:WILKE
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:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:760-317-5797
Mailing Address - Fax:
Practice Address - Street 1:11878 AVENUE OF INDUSTRY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128
Practice Address - Country:US
Practice Address - Phone:760-317-5797
Practice Address - Fax:858-312-5825
Is Sole Proprietor?:Yes
Enumeration Date:2012-05-29
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR21532084P0800X
CA20A131312084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry