Provider Demographics
NPI:1750446936
Name:WILCOX, GILBERT M (MD)
Entity Type:Individual
Prefix:DR
First Name:GILBERT
Middle Name:M
Last Name:WILCOX
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 1:161 MARGINAL WAY
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-2438
Mailing Address - Country:US
Mailing Address - Phone:207-774-3461
Mailing Address - Fax:207-774-3463
Practice Address - Street 1:161 MARGINAL WAY
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-2438
Practice Address - Country:US
Practice Address - Phone:207-773-7964
Practice Address - Fax:207-773-9073
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-27
Last Update Date:2019-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME0102139174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME100003458OtherRAILROAD MEDICARE
ME01-0418797OtherFEDERAL TAX ID
ME117070000Medicaid
MEE001889OtherTRICARE
ME037916OtherANTHEM STAR NUMBER