Provider Demographics
NPI:1184703217
Name:WILKES, ROBERT MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:MICHAEL
Last Name:WILKES
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 1:205 DE ANZA BLVD
Mailing Address - Street 2:131
Mailing Address - City:SAN MATEO
Mailing Address - State:CA
Mailing Address - Zip Code:94402-3989
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:205 DE ANZA BLVD
Practice Address - Street 2:131
Practice Address - City:SAN MATEO
Practice Address - State:CA
Practice Address - Zip Code:94402-3989
Practice Address - Country:US
Practice Address - Phone:650-888-1196
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2016-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG15217207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G152170Medicaid
A39468Medicare UPIN
00G152170Medicare ID - Type Unspecified