Provider Demographics
NPI:1578522512
Name:WILK, WITOLD A (DO)
Entity Type:Individual
Prefix:MR
First Name:WITOLD
Middle Name:A
Last Name:WILK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WOODLAND DR
Mailing Address - Street 2:
Mailing Address - City:RADCLIFF
Mailing Address - State:KY
Mailing Address - Zip Code:40160-2678
Mailing Address - Country:US
Mailing Address - Phone:270-351-6036
Mailing Address - Fax:270-351-6042
Practice Address - Street 1:111 N WOODLAND DR
Practice Address - Street 2:
Practice Address - City:RADCLIFF
Practice Address - State:KY
Practice Address - Zip Code:40160-2678
Practice Address - Country:US
Practice Address - Phone:270-351-6036
Practice Address - Fax:270-351-6042
Is Sole Proprietor?:No
Enumeration Date:2006-03-20
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY02481207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY0381801Medicare ID - Type Unspecified
KYG43704Medicare UPIN