Provider Demographics
NPI:1154360824
Name:WILKAITIS, JOHN ELGIN (MD,MBA, MS)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:ELGIN
Last Name:WILKAITIS
Suffix:
Gender:M
Credentials:MD,MBA, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 GRANDVIEW CIR
Mailing Address - Street 2:
Mailing Address - City:BRANDON
Mailing Address - State:MS
Mailing Address - Zip Code:39047-7398
Mailing Address - Country:US
Mailing Address - Phone:601-829-4170
Mailing Address - Fax:
Practice Address - Street 1:4500 INTERSTATE 55 FRONTAGE ROAD N
Practice Address - Street 2:SUITE 234
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39211-5931
Practice Address - Country:US
Practice Address - Phone:601-982-8531
Practice Address - Fax:888-735-7202
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2024-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS174352084P0800X, 2084P0804X
MO20050217112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03932074Medicaid
MO207430414Medicaid
MS$$$$$$$$$OtherBLUE CROSS
MO935174475Medicare ID - Type UnspecifiedMISSOURI MEDICARE
MS$$$$$$$$$OtherBLUE CROSS
I40784Medicare UPIN