Provider Demographics
NPI:1629015821
Name:WILKERSON, LORNA A (MD)
Entity Type:Individual
Prefix:
First Name:LORNA
Middle Name:A
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20 WALL STREET
Practice Address - Street 2:HARVARD VANGUARD
Practice Address - City:BURLINGTON
Practice Address - State:MA
Practice Address - Zip Code:01803
Practice Address - Country:US
Practice Address - Phone:781-221-2940
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153594207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3173496Medicaid
MA3173496Medicaid