Provider Demographics
NPI:1164523247
Name:WILBORN, SONALI NITIN (MD)
Entity Type:Individual
Prefix:
First Name:SONALI
Middle Name:NITIN
Last Name:WILBORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SONALI
Other - Middle Name:NITIN
Other - Last Name:NAYAK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3200 GREENFIELD RD
Mailing Address - Street 2:SUITE 250
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48120-1802
Mailing Address - Country:US
Mailing Address - Phone:313-563-3332
Mailing Address - Fax:313-563-3342
Practice Address - Street 1:18181 OAKWOOD BLVD
Practice Address - Street 2:STE 208
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-5032
Practice Address - Country:US
Practice Address - Phone:313-271-5565
Practice Address - Fax:313-271-1053
Is Sole Proprietor?:No
Enumeration Date:2006-09-25
Last Update Date:2010-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301071894207R00000X, 208M00000X, 207RH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207RH0002XAllopathic & Osteopathic PhysiciansInternal MedicineHospice and Palliative Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110H243080OtherBCBSM
MI1108294772OtherBCBS
MI1427297712Medicaid
MI4535861-10Medicaid
MIH48635Medicare UPIN
MI0M82540018Medicare PIN
MIMI1494001Medicare PIN