Provider Demographics
NPI:1407926389
Name:WILKOV, JANE LOUISE (MD)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:LOUISE
Last Name:WILKOV
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 WINN WAY
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30030-2106
Mailing Address - Country:US
Mailing Address - Phone:404-508-1177
Mailing Address - Fax:404-508-9640
Practice Address - Street 1:350 WINN WAY
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030-2106
Practice Address - Country:US
Practice Address - Phone:404-508-1177
Practice Address - Fax:404-508-9640
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA027689208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00325036BMedicare ID - Type Unspecified