Provider Demographics
NPI:1326180688
Name:WILK, LEONARD MARK (MD)
Entity Type:Individual
Prefix:DR
First Name:LEONARD
Middle Name:MARK
Last Name:WILK
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 1:2825 E BARNETT RD
Mailing Address - Street 2:MSS
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8332
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:541-789-4806
Practice Address - Street 1:2841 AVENUE G SUITE
Practice Address - Street 2:SUITE 100
Practice Address - City:WHITE CITY
Practice Address - State:OR
Practice Address - Zip Code:97503-3030
Practice Address - Country:US
Practice Address - Phone:541-826-5252
Practice Address - Fax:541-789-5785
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2023-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD29044207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500605321Medicaid
ORR147454Medicare PIN