Provider Demographics
NPI:1124025879
Name:WILBORN, BRADY L (OD)
Entity Type:Individual
Prefix:
First Name:BRADY
Middle Name:L
Last Name:WILBORN
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:202 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:CALIFORNIA
Mailing Address - State:MO
Mailing Address - Zip Code:65018-1583
Mailing Address - Country:US
Mailing Address - Phone:573-796-2222
Mailing Address - Fax:573-796-4184
Practice Address - Street 1:202 E NORTH ST
Practice Address - Street 2:
Practice Address - City:CALIFORNIA
Practice Address - State:MO
Practice Address - Zip Code:65018-1583
Practice Address - Country:US
Practice Address - Phone:573-796-2222
Practice Address - Fax:573-796-4184
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2007-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1608152W00000X
MO168620152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100406140BMedicaid
KSU87122Medicare UPIN
KS650921Medicare ID - Type Unspecified