Provider Demographics
NPI:1588619738
Name:WILKINSON, MARK J (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:J
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:PO BOX 5576
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37602-5576
Mailing Address - Country:US
Mailing Address - Phone:423-926-6266
Mailing Address - Fax:423-926-7599
Practice Address - Street 1:101 MED TECH PKWY
Practice Address - Street 2:SUITE 305
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37604-4007
Practice Address - Country:US
Practice Address - Phone:423-926-6266
Practice Address - Fax:423-926-7599
Is Sole Proprietor?:No
Enumeration Date:2006-05-24
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD27138207Q00000X
TN27138207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3096514Medicaid
VA1588619738Medicaid
NC890544QMedicaid
KY64068216Medicaid
TN3096515Medicaid
930067763OtherRR MEDICARE
NC890544QMedicaid
TN103I930175Medicare PIN
VA1588619738Medicaid
TN3096515Medicaid