Provider Demographics
NPI:1790874469
Name:WILKERSON, WILLIAM III (DC)
Entity Type:Individual
Prefix:
First Name:WILLIAM
Middle Name:
Last Name:WILKERSON
Suffix:III
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:802 S 10TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEESVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71446-4612
Mailing Address - Country:US
Mailing Address - Phone:337-238-5338
Mailing Address - Fax:337-238-5340
Practice Address - Street 1:802 S 10TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:LEESVILLE
Practice Address - State:LA
Practice Address - Zip Code:71446-4612
Practice Address - Country:US
Practice Address - Phone:337-238-5338
Practice Address - Fax:337-238-5340
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2008-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CADC29021111N00000X
LA1490111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CADC0290210OtherBLUE SHIELD
CADC0290210OtherBLUE SHIELD
CADC0290210OtherBLUE SHIELD
CADC29021Medicare ID - Type Unspecified