Provider Demographics
NPI:1528081726
Name:WILKES, KENNETH ROGER (MD)
Entity type:Individual
Prefix:DR
First Name:KENNETH
Middle Name:ROGER
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 1:146 MANETTO HILL RD
Mailing Address - Street 2:
Mailing Address - City:PLAINVIEW
Mailing Address - State:NY
Mailing Address - Zip Code:11803
Mailing Address - Country:US
Mailing Address - Phone:516-938-3866
Mailing Address - Fax:516-938-4596
Practice Address - Street 1:146 MANETTO HILL RD
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803
Practice Address - Country:US
Practice Address - Phone:516-938-3866
Practice Address - Fax:516-938-4596
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-26
Last Update Date:2010-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYMD1167622084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00679034Medicaid
NY966451Medicare ID - Type Unspecified
NYC12525Medicare UPIN