Provider Demographics
NPI:1982656963
Name:WILKIN, TERRENCE D (MD)
Entity Type:Individual
Prefix:DR
First Name:TERRENCE
Middle Name:D
Last Name:WILKIN
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 1:121 S SAINT LOUIS BLVD
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46617-2924
Mailing Address - Country:US
Mailing Address - Phone:574-233-3123
Mailing Address - Fax:574-233-3125
Practice Address - Street 1:611 E DOUGLAS RD STE 200
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46545-1465
Practice Address - Country:US
Practice Address - Phone:574-272-5347
Practice Address - Fax:574-272-8617
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2020-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048976A2085R0202X, 2085R0204X, 2085R0202X, 2085R0204X
MI43010869432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Yes2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4840231Medicaid
IN201054420Medicaid
IN201054420Medicaid
INM400063524Medicare PIN
IN201054420Medicaid