Basic Information
| Provider Information | |||||||||
| NPI: | 1396937074 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1735 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 846041010 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013741818 | ||||||||
| FaxNumber: | 8013740163 | ||||||||
| Practice Location | |||||||||
| Address1: | 1735 N STATE ST | ||||||||
| Address2: | |||||||||
| City: | PROVO | ||||||||
| State: | UT | ||||||||
| PostalCode: | 84604 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8013741818 | ||||||||
| FaxNumber: | 8013740163 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2007 | ||||||||
| LastUpdateDate: | 06/28/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | MD154095 | OR | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 8227125-1205 | UT | N | Allopathic & Osteopathic Physicians | Ophthalmology | 390200000X | LL17376 | OR | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207WX0120X | 8227125-1205 | UT | Y |
No ID Information.