Provider Demographics
NPI:1245212844
Name:WILKERSON, BOBBY S (MD)
Entity Type:Individual
Prefix:
First Name:BOBBY
Middle Name:S
Last Name:WILKERSON
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 1:1227 N STATE ST
Mailing Address - Street 2:SUITE 101
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2002
Mailing Address - Country:US
Mailing Address - Phone:601-355-2485
Mailing Address - Fax:601-353-1463
Practice Address - Street 1:1227 N STATE ST
Practice Address - Street 2:SUITE 101
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2002
Practice Address - Country:US
Practice Address - Phone:601-355-2485
Practice Address - Fax:601-353-1463
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS17599207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS04883219Medicaid
MS7271728OtherAETNA US HEALTHCARE
MS110001898Medicare PIN
MSI40298Medicare UPIN
MSI40298Medicare UPIN