Basic Information
| Provider Information | |||||||||
| NPI: | 1407897226 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILKINSON | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | DARRIN | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4008 | ||||||||
| Address2: | |||||||||
| City: | PORTLAND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 972084008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033722740 | ||||||||
| FaxNumber: | 5033722754 | ||||||||
| Practice Location | |||||||||
| Address1: | 2500 NE NEFF ROAD | ||||||||
| Address2: | |||||||||
| City: | BEND | ||||||||
| State: | OR | ||||||||
| PostalCode: | 97701 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5413824321 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/10/2006 | ||||||||
| LastUpdateDate: | 03/27/2008 | ||||||||
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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 | 207L00000X | MD21485 | OR | Y | Allopathic & Osteopathic Physicians | Anesthesiology | 207L00000X | G62586 | CA | N | Allopathic & Osteopathic Physicians | Anesthesiology |
ID Information
| ID | Type | State | Issuer | Description | 135098 | 05 | OR | MEDICAID | 00G625860 | 05 | CA | MEDICAID |