Provider Demographics
NPI:1568621803
Name:WILKINSON, JOHN BENJAMIN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:BENJAMIN
Last Name:WILKINSON
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 1:1213 E OCEAN AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:LOMPOC
Mailing Address - State:CA
Mailing Address - Zip Code:93436-7043
Mailing Address - Country:US
Mailing Address - Phone:057-368-6288
Mailing Address - Fax:805-736-8785
Practice Address - Street 1:1213 E OCEAN AVE STE 100
Practice Address - Street 2:
Practice Address - City:LOMPOC
Practice Address - State:CA
Practice Address - Zip Code:93436-7043
Practice Address - Country:US
Practice Address - Phone:057-368-6288
Practice Address - Fax:805-736-8785
Is Sole Proprietor?:No
Enumeration Date:2008-06-02
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN551162085R0001X
LAMD.2060162085R0001X
CAC1563102085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2338196Medicaid
0042452674OtherPECOS