Provider Demographics
NPI:1346315355
Name:WILKES, JEFF THOMAS (MD)
Entity Type:Individual
Prefix:DR
First Name:JEFF
Middle Name:THOMAS
Last Name:WILKES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:J.
Other - Middle Name:THOMAS
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:2330 W COVELL BLVD
Mailing Address - Street 2:
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95616-5658
Mailing Address - Country:US
Mailing Address - Phone:530-756-2364
Mailing Address - Fax:
Practice Address - Street 1:2330 W COVELL BLVD
Practice Address - Street 2:
Practice Address - City:DAVIS
Practice Address - State:CA
Practice Address - Zip Code:95616-5658
Practice Address - Country:US
Practice Address - Phone:530-756-2364
Practice Address - Fax:530-756-5817
Is Sole Proprietor?:No
Enumeration Date:2006-11-22
Last Update Date:2009-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG13654207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G136540OtherBLUE SHIELD
CA00G136540Medicaid
CA080086111OtherRR MEDICARE
CAAN443YMedicare PIN
CA00G136540OtherBLUE SHIELD
CA080086111OtherRR MEDICARE