Provider Demographics
NPI:1205836335
Name:WILKS, DAVID C (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:WILKS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:9660 WICKER AVE
Mailing Address - Street 2:
Mailing Address - City:ST JOHN
Mailing Address - State:IN
Mailing Address - Zip Code:46373-9487
Mailing Address - Country:US
Mailing Address - Phone:219-226-2203
Mailing Address - Fax:219-226-2202
Practice Address - Street 1:1400 S LAKE PARK AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:HOBART
Practice Address - State:IN
Practice Address - Zip Code:46342-6790
Practice Address - Country:US
Practice Address - Phone:219-942-5599
Practice Address - Fax:219-942-5544
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2012-11-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IN01031776A208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100406800Medicaid
IN256700COtherMEDICARE PTAN
IN256700COtherMEDICARE PTAN