Provider Demographics
NPI:1003925975
Name:WILBUR, LEE G (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:G
Last Name:WILBUR
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 1:950 N MERIDIAN ST
Mailing Address - Street 2:STE 500 PROVIDER ENROLLMENT
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46204-3908
Mailing Address - Country:US
Mailing Address - Phone:317-962-4945
Mailing Address - Fax:317-962-4950
Practice Address - Street 1:1701 N SENATE BLVD
Practice Address - Street 2:RM AG001
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-1239
Practice Address - Country:US
Practice Address - Phone:317-962-3886
Practice Address - Fax:317-962-8652
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2011-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058967A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000331511OtherANTHEM
IN200238230Medicaid
INP00924303OtherRAILROAD MEDICARE PTAN
INI17977Medicare UPIN
IN200238230Medicaid
IN160840HHHMedicare ID - Type Unspecified