Provider Demographics
NPI:1326065848
Name:WILSHIRE, LARRY BRENT (MD)
Entity Type:Individual
Prefix:DR
First Name:LARRY
Middle Name:BRENT
Last Name:WILSHIRE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:L.
Other - Middle Name:BRENT
Other - Last Name:WILSHIRE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:201 DAVID PL
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-4546
Mailing Address - Country:US
Mailing Address - Phone:910-346-2085
Mailing Address - Fax:910-347-6663
Practice Address - Street 1:6 OFFICE PARK DR
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-7325
Practice Address - Country:US
Practice Address - Phone:910-355-3937
Practice Address - Fax:910-347-6663
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2007-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27869207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8988165Medicaid
NC88165OtherBLUECROSS BLUESHIELD
NC8988165Medicaid
C86812Medicare UPIN
1314390001Medicare NSC