Provider Demographics
NPI:1871630186
Name:DEDWYLDER, WILKINS (MD)
Entity Type:Individual
Prefix:DR
First Name:WILKINS
Middle Name:
Last Name:DEDWYLDER
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 1:2010 PAULDING RD
Mailing Address - Street 2:
Mailing Address - City:LEAKESVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39451-3055
Mailing Address - Country:US
Mailing Address - Phone:601-394-2975
Mailing Address - Fax:
Practice Address - Street 1:1017 JACKSON AVE
Practice Address - Street 2:
Practice Address - City:LEAKESVILLE
Practice Address - State:MS
Practice Address - Zip Code:39451-9105
Practice Address - Country:US
Practice Address - Phone:601-394-4135
Practice Address - Fax:601-394-4455
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-30
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS08328207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01658391Medicaid
MS302I935535Medicare PIN
MS01658391Medicaid