1790758613 NPI number — DR. BENJAMIN STUART WILBUR M.D.

Table of content: DR. BENJAMIN STUART WILBUR M.D. (NPI 1790758613)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790758613 NPI number — DR. BENJAMIN STUART WILBUR M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILBUR
Provider First Name:
BENJAMIN
Provider Middle Name:
STUART
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790758613
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/13/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
12762 LIMONITE AVE
Provider Second Line Business Mailing Address:
#3E-235
Provider Business Mailing Address City Name:
EASTVALE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92880-4208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
951-427-0001
Provider Business Mailing Address Fax Number:
909-483-1063

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1155 NORTH VERMONT AVE
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
LOS ANGELES
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90029-1728
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-664-1814
Provider Business Practice Location Address Fax Number:
323-663-1723
Provider Enumeration Date:
02/10/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208D00000X , with the licence number:  A92956 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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