Provider Demographics
NPI:1417036146
Name:WILBORN, DOROTHY L (MD)
Entity Type:Individual
Prefix:
First Name:DOROTHY
Middle Name:L
Last Name:WILBORN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 HARRISON ST FL 7
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94612-3466
Mailing Address - Country:US
Mailing Address - Phone:510-625-6262
Mailing Address - Fax:
Practice Address - Street 1:2025 MORSE AVE
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825-2115
Practice Address - Country:US
Practice Address - Phone:916-973-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-03
Last Update Date:2021-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA71472208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A714720Medicaid
00A714720Medicare ID - Type Unspecified
H27191Medicare UPIN