Provider Demographics
NPI:1205818358
Name:WILKING, SPENCER VANB (MD)
Entity Type:Individual
Prefix:DR
First Name:SPENCER
Middle Name:VANB
Last Name:WILKING
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:PO BOX 9142
Mailing Address - Street 2:MASS GENERAL PHYSICIAN ORGANIZATION
Mailing Address - City:CHARLESTOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02129-9142
Mailing Address - Country:US
Mailing Address - Phone:617-724-0287
Mailing Address - Fax:617-726-2894
Practice Address - Street 1:100 CHARLES RIVER PLAZA
Practice Address - Street 2:STE 501 CPZ 100-5
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02114-2723
Practice Address - Country:US
Practice Address - Phone:617-726-2066
Practice Address - Fax:617-288-6306
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA53519207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Not Answered207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA053519OtherTUFTS HEALTH PLAN
MAJ05095OtherBCBS MA
MA3002551Medicaid
MA3002551Medicaid
MAJ05095Medicare ID - Type Unspecified