Provider Demographics
NPI:1639295066
Name:JONATHAN D WILKS MD PC
Entity Type:Organization
Organization Name:JONATHAN D WILKS MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:PAMELA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BANKSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-755-7672
Mailing Address - Street 1:4140 W MEMORIAL RD
Mailing Address - Street 2:SUITE 208
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-8366
Mailing Address - Country:US
Mailing Address - Phone:405-755-4290
Mailing Address - Fax:405-755-7773
Practice Address - Street 1:4140 W MEMORIAL RD
Practice Address - Street 2:SUITE 208
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-8366
Practice Address - Country:US
Practice Address - Phone:405-755-4290
Practice Address - Fax:405-755-7773
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK21132207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1740385533OtherINDIVIDUAL NPI
OKG77013Medicare UPIN