Provider Demographics
NPI:1548265051
Name:WILKES, GARY MASON (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:MASON
Last Name:WILKES
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 1:28249 SHAKER BLVD
Mailing Address - Street 2:
Mailing Address - City:PEPPER PIKE
Mailing Address - State:OH
Mailing Address - Zip Code:44124-5006
Mailing Address - Country:US
Mailing Address - Phone:216-464-2795
Mailing Address - Fax:216-765-0448
Practice Address - Street 1:23811 CHAGRIN BLVD
Practice Address - Street 2:STE 170
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122-5525
Practice Address - Country:US
Practice Address - Phone:216-765-0440
Practice Address - Fax:216-765-0448
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2009-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH350495602084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0602486Medicaid
OH0563616Medicare PIN
OHA15986Medicare UPIN
OH0602486Medicaid