Provider Demographics
NPI:1396937074
Name:WILKINSON, JUSTIN (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1735 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84604-1010
Mailing Address - Country:US
Mailing Address - Phone:801-374-1818
Mailing Address - Fax:801-374-0163
Practice Address - Street 1:1735 N STATE ST
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84604
Practice Address - Country:US
Practice Address - Phone:801-374-1818
Practice Address - Fax:801-374-0163
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2018-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD154095207W00000X
UT8227125-1205207W00000X, 207WX0120X
ORLL17376390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0120XAllopathic & Osteopathic PhysiciansOphthalmologyCornea and External Diseases Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT000076081Medicare PIN