Provider Demographics
NPI:1811108087
Name:WILKES, DAVID ROSS (PHD)
Entity type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ROSS
Last Name:WILKES
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 SONGSPARROW LN
Mailing Address - Street 2:
Mailing Address - City:CENTEREACH
Mailing Address - State:NY
Mailing Address - Zip Code:11720-4323
Mailing Address - Country:US
Mailing Address - Phone:163-198-1260
Mailing Address - Fax:163-198-1260
Practice Address - Street 1:17 SONGSPARROW LN
Practice Address - Street 2:
Practice Address - City:CENTEREACH
Practice Address - State:NY
Practice Address - Zip Code:11720-4323
Practice Address - Country:US
Practice Address - Phone:163-198-1260
Practice Address - Fax:163-198-1260
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY000673102L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes102L00000XBehavioral Health & Social Service ProvidersPsychoanalyst