Provider Demographics
NPI:1679678429
Name:WILKENS, DARRYL JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:DARRYL
Middle Name:JOHN
Last Name:WILKENS
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 447
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0447
Mailing Address - Country:US
Mailing Address - Phone:423-784-7269
Mailing Address - Fax:423-784-3708
Practice Address - Street 1:131 HOSPITAL LN
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4404
Practice Address - Country:US
Practice Address - Phone:423-784-7269
Practice Address - Fax:423-784-3708
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD0000030038207Q00000X
KY35440207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY64712748Medicaid
TN3836057Medicaid
87933Medicare UPIN
KY329111Medicare ID - Type Unspecified
TN3836056Medicare ID - Type Unspecified