Provider Demographics
NPI:1649658683
Name:WILKES FAMILY MEDICINE
Entity type:Organization
Organization Name:WILKES FAMILY MEDICINE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:DANNELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCDERMOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-499-4446
Mailing Address - Street 1:400 S REINO RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWBURY PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91320-4284
Mailing Address - Country:US
Mailing Address - Phone:805-499-4446
Mailing Address - Fax:
Practice Address - Street 1:400 S REINO RD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWBURY PARK
Practice Address - State:CA
Practice Address - Zip Code:91320-4284
Practice Address - Country:US
Practice Address - Phone:805-499-4446
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA85368332900000X, 261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No332900000XSuppliersNon-Pharmacy Dispensing Site
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABY173AMedicare PIN