Provider Demographics
NPI:1124158266
Name:WILKERSON, CHARLES R (DC)
Entity type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:R
Last Name:WILKERSON
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
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Mailing Address - Street 1:4432 ALDERGATE DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30035-2104
Mailing Address - Country:US
Mailing Address - Phone:770-987-4631
Mailing Address - Fax:404-299-9991
Practice Address - Street 1:1230 S HAIRSTON RD
Practice Address - Street 2:SUITE 8
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30088-2719
Practice Address - Country:US
Practice Address - Phone:404-299-9066
Practice Address - Fax:404-299-9991
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-07
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAGA4956111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAU64623Medicare UPIN
GA35ZCCTDMedicare ID - Type Unspecified