Provider Demographics
NPI:1184833188
Name:WILKERSON, BENJAMIN WADE (MD)
Entity type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:WADE
Last Name:WILKERSON
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:PO BOX 2277
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70404-2277
Mailing Address - Country:US
Mailing Address - Phone:985-543-6079
Mailing Address - Fax:985-350-9950
Practice Address - Street 1:15837 PAUL VEGA MD DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-1495
Practice Address - Country:US
Practice Address - Phone:985-543-6079
Practice Address - Fax:985-350-9950
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA2045332085R0202X
MS202802085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03070723Medicaid
LA2153498Medicaid