Provider Demographics
NPI:1649297227
Name:WILKERSON, SUZANNE M (MD)
Entity type:Individual
Prefix:
First Name:SUZANNE
Middle Name:M
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SUZANNE
Other - Middle Name:M
Other - Last Name:PUCCINELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:4425 N PORT WASHINGTON RD
Mailing Address - Street 2:ATTN: CSMCP CLINIC CREDENTIALING
Mailing Address - City:GLENDALE
Mailing Address - State:WI
Mailing Address - Zip Code:53212-1082
Mailing Address - Country:US
Mailing Address - Phone:414-270-4932
Mailing Address - Fax:
Practice Address - Street 1:2320 N LAKE DR
Practice Address - Street 2:ROOM 3603
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53211-4507
Practice Address - Country:US
Practice Address - Phone:414-270-4932
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI38093207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32447800Medicaid
WI32447800Medicaid