Provider Demographics
NPI:1124197389
Name:WILK, PETER DAVID (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:DAVID
Last Name:WILK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:95 INDIA ST
Mailing Address - Street 2:THIRD FLOOR
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04101-4250
Mailing Address - Country:US
Mailing Address - Phone:207-619-4260
Mailing Address - Fax:
Practice Address - Street 1:95 INDIA ST
Practice Address - Street 2:THIRD FLOOR
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04101-4250
Practice Address - Country:US
Practice Address - Phone:207-619-4260
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2012-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME109022084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME015173Medicare UPIN