Provider Demographics
NPI:1477641108
Name:WILKERSON, MARK HOWARD (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:HOWARD
Last Name:WILKERSON
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 1:400 S LOOP 336 W
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3302
Mailing Address - Country:US
Mailing Address - Phone:936-539-4500
Mailing Address - Fax:936-539-4050
Practice Address - Street 1:400 S LOOP 336 W
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3302
Practice Address - Country:US
Practice Address - Phone:936-539-4500
Practice Address - Fax:936-539-4050
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH0938207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX097848802Medicaid
GA180014075Medicare PIN
TX097848802Medicaid
TX86M962Medicare PIN