Provider Demographics
NPI:1679598544
Name:WILKERSON, CARLOS J (MD)
Entity Type:Individual
Prefix:DR
First Name:CARLOS
Middle Name:J
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 1:7663 W SUMMER SCENE DR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85743-5184
Mailing Address - Country:US
Mailing Address - Phone:610-529-1214
Mailing Address - Fax:
Practice Address - Street 1:7663 W SUMMER SCENE DR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85743-5184
Practice Address - Country:US
Practice Address - Phone:610-529-1214
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041502E207L00000X
AZ58022207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5029201Medicaid
PA001247110Medicaid
PA677023Medicare PIN