Provider Demographics
NPI:1285849166
Name:RANDALL M. WILK, MD, DDS, PHD, APMC
Entity Type:Organization
Organization Name:RANDALL M. WILK, MD, DDS, PHD, APMC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:RANDALL
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:504-362-6135
Mailing Address - Street 1:120 MEADOWCREST ST, #300
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:LA
Mailing Address - Zip Code:70056
Mailing Address - Country:US
Mailing Address - Phone:504-362-6135
Mailing Address - Fax:504-362-6134
Practice Address - Street 1:120 MEADOWCREST ST, #300
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:LA
Practice Address - Zip Code:70056
Practice Address - Country:US
Practice Address - Phone:504-362-6135
Practice Address - Fax:504-362-6134
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-13
Last Update Date:2013-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA46691223S0112X
LA022962204E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes204E00000XAllopathic & Osteopathic PhysiciansOral & Maxillofacial SurgeryGroup - Multi-Specialty
No1223S0112XDental ProvidersDentistOral and Maxillofacial SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1890197Medicaid
LA5T353CX80Medicare PIN
LA1890197Medicaid