Provider Demographics
NPI:1437708781
Name:WILKERSON, SAMUEL DONNALL
Entity Type:Individual
Prefix:MR
First Name:SAMUEL
Middle Name:DONNALL
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1114 OAKGROVE AVE
Mailing Address - Street 2:
Mailing Address - City:MARTINSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:24112-4811
Mailing Address - Country:US
Mailing Address - Phone:336-520-4381
Mailing Address - Fax:276-595-1185
Practice Address - Street 1:1114 OAKGROVE AVE
Practice Address - Street 2:
Practice Address - City:MARTINSVILLE
Practice Address - State:VA
Practice Address - Zip Code:24112-4811
Practice Address - Country:US
Practice Address - Phone:336-520-4381
Practice Address - Fax:276-595-1185
Is Sole Proprietor?:No
Enumeration Date:2019-09-10
Last Update Date:2019-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAT60237004172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver