Provider Demographics
NPI:1609148162
Name:WILBUR SUESBERRY MD INC A MEDICAL CORP
Entity Type:Organization
Organization Name:WILBUR SUESBERRY MD INC A MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:WILBUR
Authorized Official - Middle Name:
Authorized Official - Last Name:SUESBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:661-721-1422
Mailing Address - Street 1:1205 GARCES HWY
Mailing Address - Street 2:SUITE 207
Mailing Address - City:DELANO
Mailing Address - State:CA
Mailing Address - Zip Code:93215-3639
Mailing Address - Country:US
Mailing Address - Phone:661-721-1422
Mailing Address - Fax:661-721-2738
Practice Address - Street 1:1205 GARCES HWY
Practice Address - Street 2:SUITE 207
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-3639
Practice Address - Country:US
Practice Address - Phone:661-721-1422
Practice Address - Fax:661-721-2738
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-30
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC29033207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
00C290330Medicare PIN