Provider Demographics
NPI:1386177251
Name:RYAN M. WILKE, D.O., A MEDICAL CORPORATION
Entity type:Organization
Organization Name:RYAN M. WILKE, D.O., A MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:MICHAEL-DAVID
Authorized Official - Last Name:WILKE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:760-317-5797
Mailing Address - Street 1:PO BOX 1770
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91944-1770
Mailing Address - Country:US
Mailing Address - Phone:760-317-5797
Mailing Address - Fax:760-739-5792
Practice Address - Street 1:11878 AVENUE OF INDUSTRY
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128
Practice Address - Country:US
Practice Address - Phone:760-317-5797
Practice Address - Fax:760-739-5792
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-07
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty