Provider Demographics
NPI:1497851067
Name:MALCOLM WILKINSON, MD
Entity Type:Organization
Organization Name:MALCOLM WILKINSON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MALCOLM
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKINSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-639-1273
Mailing Address - Street 1:PO BOX 3425
Mailing Address - Street 2:
Mailing Address - City:COTTONWOOD
Mailing Address - State:AZ
Mailing Address - Zip Code:86326-2598
Mailing Address - Country:US
Mailing Address - Phone:928-634-0665
Mailing Address - Fax:
Practice Address - Street 1:300 S WILLARD ST
Practice Address - Street 2:STE 101
Practice Address - City:COTTONWOOD
Practice Address - State:AZ
Practice Address - Zip Code:86326-4159
Practice Address - Country:US
Practice Address - Phone:928-639-1273
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ21001207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ113895Medicaid
AZ113895Medicaid
AZZ63911Medicare PIN