Provider Demographics
NPI:1770506479
Name:WILKES, SHELBY RAY (MD)
Entity Type:Individual
Prefix:DR
First Name:SHELBY
Middle Name:RAY
Last Name:WILKES
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:830 W PEACHTREE ST NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30308-1129
Mailing Address - Country:US
Mailing Address - Phone:404-881-6417
Mailing Address - Fax:404-876-7565
Practice Address - Street 1:830 W PEACHTREE ST NW
Practice Address - Street 2:SUITE 100
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30308-1129
Practice Address - Country:US
Practice Address - Phone:404-881-6417
Practice Address - Fax:404-876-7565
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2012-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024884174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000273006BMedicaid
4231404OtherAETNA PPO
GA10039025OtherAMERIGROUP
GA153697OtherBCBS
GA180009231OtherRAILROAD MEDICARE
GA581515266OtherPEACH STATE HEALTH PLAN
GA309322OtherWELLCARE OF GEORGIA
581515266OtherTAX IDENTIFICATION NUMBER
2312437OtherAETNA HMO
GA581515266OtherPEACH STATE HEALTH PLAN