Provider Demographics
NPI:1992743777
Name:WILKINSON, LOUISE (DO)
Entity type:Individual
Prefix:DR
First Name:LOUISE
Middle Name:
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1333 S SAM HOUSTON BLVD
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:MO
Mailing Address - Zip Code:65483-2046
Mailing Address - Country:US
Mailing Address - Phone:417-967-3311
Mailing Address - Fax:417-967-1259
Practice Address - Street 1:1333 S SAM HOUSTON BLVD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:MO
Practice Address - Zip Code:65483-2046
Practice Address - Country:US
Practice Address - Phone:417-967-3311
Practice Address - Fax:417-967-1259
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2012-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36687207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992743777Medicaid
MO242547016Medicaid
MO26D0446923OtherCLIA
MO329073213Medicare PIN
MO26D0446923OtherCLIA
MOD41755Medicare UPIN
MO021050080Medicare ID - Type UnspecifiedMEDICARE PART B