Provider Demographics
NPI:1518061944
Name:WILKES, EMANUEL SR (MD)
Entity Type:Individual
Prefix:DR
First Name:EMANUEL
Middle Name:
Last Name:WILKES
Suffix:SR
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 1:822 22ND ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31904-8823
Mailing Address - Country:US
Mailing Address - Phone:706-327-9965
Mailing Address - Fax:706-327-7798
Practice Address - Street 1:822 22ND STREET
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31904
Practice Address - Country:US
Practice Address - Phone:706-327-9965
Practice Address - Fax:706-327-7798
Is Sole Proprietor?:No
Enumeration Date:2006-09-07
Last Update Date:2013-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA28335174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00326906AMedicaid
180038689GOtherRR MCARE
GA52237056001OtherBCBS GA
GA00326906AMedicaid