Provider Demographics
NPI:1558554261
Name:WILBUR, DOROTHY MARIE
Entity Type:Individual
Prefix:MISS
First Name:DOROTHY
Middle Name:MARIE
Last Name:WILBUR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:96 WATERMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12205-3628
Mailing Address - Country:US
Mailing Address - Phone:518-456-2030
Mailing Address - Fax:
Practice Address - Street 1:96 WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12205-3628
Practice Address - Country:US
Practice Address - Phone:518-456-2030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-27
Last Update Date:2007-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY373020-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02063252Medicaid