Provider Demographics
NPI:1134214596
Name:WILKENS, GREGORY CHARLES (MD)
Entity type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHARLES
Last Name:WILKENS
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 1:509 MEMORIAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:KY
Mailing Address - Zip Code:40962-6196
Mailing Address - Country:US
Mailing Address - Phone:606-598-5104
Mailing Address - Fax:606-598-0983
Practice Address - Street 1:515 MEMORIAL DR STE 1
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:KY
Practice Address - Zip Code:40962-9157
Practice Address - Country:US
Practice Address - Phone:606-598-4534
Practice Address - Fax:606-599-2524
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2020-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38097208600000X
TNMD0000035379208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3885392Medicaid
KY64064413Medicaid
TN3885392Medicaid
KY0906103Medicare ID - Type Unspecified
KY64064413Medicaid