Provider Demographics
NPI:1770564148
Name:WILCOX, DENNIS M (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:M
Last Name:WILCOX
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 1:23625 COMMERCE PARK
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-255-5701
Mailing Address - Fax:216-255-5701
Practice Address - Street 1:3904 W 125TH TERRACE
Practice Address - Street 2:
Practice Address - City:LEAWOOD
Practice Address - State:KS
Practice Address - Zip Code:66209-2643
Practice Address - Country:US
Practice Address - Phone:216-255-5700
Practice Address - Fax:216-255-5701
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2011-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS280512085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS300134281OtherRXR MEDICARE
NE34195845104Medicaid
341958451004OtherTRICARE WEST
AZ73381701Medicaid
OH341958451010OtherMEDICAL MUTUAL
KS12705151OtherBCBS
KS200002820AMedicaid
OH2345457Medicaid
KY6409641500Medicaid
ID806480700Medicaid
PA1017159110001Medicaid
341958451004OtherTRICARE WEST
NE34195845104Medicaid
KSM915877Medicare PIN