Provider Demographics
NPI:1609839117
Name:WILKERSON, BRUCE (MD)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:
Last Name:WILKERSON
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 1:8124 WALDEN RD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-5945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1305 CROWLEY RAYNE HWY
Practice Address - Street 2:
Practice Address - City:CROWLEY
Practice Address - State:LA
Practice Address - Zip Code:70526-8202
Practice Address - Country:US
Practice Address - Phone:800-893-9698
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA019768208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1377601Medicaid
LA4E589CM70Medicare ID - Type Unspecified
LA1377601Medicaid