Provider Demographics
NPI:1558441444
Name:WILBORN, JOHNNY R (MD)
Entity Type:Individual
Prefix:
First Name:JOHNNY
Middle Name:R
Last Name:WILBORN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 MEDICAL CENTER DR
Mailing Address - Street 2:#207
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-1134
Mailing Address - Country:US
Mailing Address - Phone:256-492-4001
Mailing Address - Fax:256-492-4031
Practice Address - Street 1:100 MEDICAL CENTER DR
Practice Address - Street 2:#207
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1134
Practice Address - Country:US
Practice Address - Phone:256-492-4001
Practice Address - Fax:256-492-4031
Is Sole Proprietor?:No
Enumeration Date:2006-10-16
Last Update Date:2009-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9133207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-95241OtherAL BCBS
AL1558441444 / 109107Medicaid
ALP00703805Medicare PIN
AL1558441444 / 109107Medicaid
ALC74343Medicare UPIN