Provider Demographics
NPI:1164775037
Name:JIMMIE JEAN WILBUR MD PA
Entity Type:Organization
Organization Name:JIMMIE JEAN WILBUR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMIE
Authorized Official - Middle Name:J
Authorized Official - Last Name:WILBUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:813-984-9700
Mailing Address - Street 1:13381 N. 56TH ST.
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33617
Mailing Address - Country:US
Mailing Address - Phone:813-984-9700
Mailing Address - Fax:813-984-2889
Practice Address - Street 1:13381 N. 56TH ST.
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33617
Practice Address - Country:US
Practice Address - Phone:813-984-9700
Practice Address - Fax:813-984-2889
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-10-17
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0067395207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL27003AMedicare UPIN