Provider Demographics
NPI:1992063879
Name:WILKS, GAVIN RAY (MD)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:RAY
Last Name:WILKS
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 1:518 COUNTY ROAD 154
Mailing Address - Street 2:
Mailing Address - City:CROSSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35962-4217
Mailing Address - Country:US
Mailing Address - Phone:256-572-0812
Mailing Address - Fax:
Practice Address - Street 1:701 UNIVERSITY BLVD E STE 604
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-7411
Practice Address - Country:US
Practice Address - Phone:205-759-6925
Practice Address - Fax:205-759-6926
Is Sole Proprietor?:No
Enumeration Date:2012-04-27
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL38426208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery