Provider Demographics
NPI:1770543837
Name:WILKINSON, MARC L (MD)
Entity type:Individual
Prefix:
First Name:MARC
Middle Name:L
Last Name:WILKINSON
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 PARKER ST
Mailing Address - Street 2:
Mailing Address - City:BOSCOBEL
Mailing Address - State:WI
Mailing Address - Zip Code:53805-1642
Mailing Address - Country:US
Mailing Address - Phone:608-375-4112
Mailing Address - Fax:
Practice Address - Street 1:205 PARKER ST
Practice Address - Street 2:
Practice Address - City:BOSCOBEL
Practice Address - State:WI
Practice Address - Zip Code:53805-1642
Practice Address - Country:US
Practice Address - Phone:608-375-4112
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2023-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA75952207Q00000X
MN64412207Q00000X
WI3493207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1770543837Medicaid
IA152504Medicaid
IAF71584Medicare UPIN