Provider Demographics
NPI:1316006539
Name:WILKS, G JASON (DPM)
Entity Type:Individual
Prefix:
First Name:G
Middle Name:JASON
Last Name:WILKS
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:GORDON
Other - Middle Name:JASON
Other - Last Name:WILKS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:DPM
Mailing Address - Street 1:2579 NW EDENBOWER BLVD
Mailing Address - Street 2:
Mailing Address - City:ROSEBURG
Mailing Address - State:OR
Mailing Address - Zip Code:97471-6220
Mailing Address - Country:US
Mailing Address - Phone:541-673-0742
Mailing Address - Fax:541-673-7553
Practice Address - Street 1:1813 W HARVARD AVE STE 201
Practice Address - Street 2:
Practice Address - City:ROSEBURG
Practice Address - State:OR
Practice Address - Zip Code:97471-2754
Practice Address - Country:US
Practice Address - Phone:541-673-0742
Practice Address - Fax:541-673-7553
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00318213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR067946000OtherREGENCE
OR7600580001OtherPTAN DME
ORDX4938OtherRR MDC GROUP PTAN
OR500720262Medicaid
OR430895102OtherREGENCE BC HMO
480028890OtherRR MEDICARE
ORR192914OtherPTAN MEDICARE ORGANIZATION
ORD201111OtherPACIFIC SOURCE