Provider Demographics
NPI:1114092723
Name:WILKINSON, JOHN R (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:R
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5555 RESERVOIR DR
Mailing Address - Street 2:SUITE 207
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5134
Mailing Address - Country:US
Mailing Address - Phone:619-255-1754
Mailing Address - Fax:619-286-4355
Practice Address - Street 1:5555 RESERVOIR DR
Practice Address - Street 2:SUITE 207
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5149
Practice Address - Country:US
Practice Address - Phone:619-255-1754
Practice Address - Fax:619-286-4355
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG50507174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA330301294OtherTAX ID
CAAW2191702OtherD.E.A.
CAG50507OtherCA LIC
CA330301294OtherTAX ID