Provider Demographics
NPI:1053310359
Name:WILBERT, LLOYD GLENWOOD III (MD)
Entity Type:Individual
Prefix:
First Name:LLOYD
Middle Name:GLENWOOD
Last Name:WILBERT
Suffix:III
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:L.
Other - Middle Name:GLEN
Other - Last Name:WILBERT
Other - Suffix:III
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:1845 PRECINCT LINE RD STE 209
Mailing Address - Street 2:
Mailing Address - City:HURST
Mailing Address - State:TX
Mailing Address - Zip Code:76054-3109
Mailing Address - Country:US
Mailing Address - Phone:817-336-4638
Mailing Address - Fax:817-336-1331
Practice Address - Street 1:1845 PRECINCT LINE RD STE 209
Practice Address - Street 2:
Practice Address - City:HURST
Practice Address - State:TX
Practice Address - Zip Code:76054-3109
Practice Address - Country:US
Practice Address - Phone:817-336-4638
Practice Address - Fax:817-336-1331
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK13202085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX300097656OtherMEDICARE RR
TX124692803Medicaid
TX300097656OtherMEDICARE RR
TX124692803Medicaid