Provider Demographics
NPI:1255317202
Name:WILKES, STEPHEN MARK (OD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:MARK
Last Name:WILKES
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2002 MERRIMAC TRL
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-1235
Mailing Address - Country:US
Mailing Address - Phone:972-840-0822
Mailing Address - Fax:214-388-4753
Practice Address - Street 1:2744 S BUCKNER BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75227-6903
Practice Address - Country:US
Practice Address - Phone:214-388-9767
Practice Address - Fax:214-388-4753
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX3238TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00E24LMedicare ID - Type Unspecified
T16628Medicare UPIN