Provider Demographics
NPI:1457812893
Name:WILCOX, SAMUEL LEWIS (MD)
Entity Type:Individual
Prefix:
First Name:SAMUEL
Middle Name:LEWIS
Last Name:WILCOX
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 1:826 E MADISON AVE
Mailing Address - Street 2:
Mailing Address - City:IOLA
Mailing Address - State:KS
Mailing Address - Zip Code:66749-3555
Mailing Address - Country:US
Mailing Address - Phone:620-365-6933
Mailing Address - Fax:620-365-8126
Practice Address - Street 1:826 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:IOLA
Practice Address - State:KS
Practice Address - Zip Code:66749-3555
Practice Address - Country:US
Practice Address - Phone:620-365-6933
Practice Address - Fax:620-365-8126
Is Sole Proprietor?:No
Enumeration Date:2019-03-28
Last Update Date:2023-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-046597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine