Provider Demographics
NPI:1629042999
Name:WILBORN, JERRY R JR (MD)
Entity Type:Individual
Prefix:
First Name:JERRY
Middle Name:R
Last Name:WILBORN
Suffix:JR
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:PO BOX 2968
Mailing Address - Street 2:
Mailing Address - City:KENNESAW
Mailing Address - State:GA
Mailing Address - Zip Code:30156-9117
Mailing Address - Country:US
Mailing Address - Phone:770-779-0015
Mailing Address - Fax:
Practice Address - Street 1:1000 JOHNSON FERRY RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1606
Practice Address - Country:US
Practice Address - Phone:404-851-6936
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA045666207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000792503JMedicaid
GA000792503Medicaid
GA000792503IMedicaid
GA006083OtherBCBS
GA10655OtherKAISER
GA00000011837Other1ST MEDICAL NETWORK
GA10038155OtherAMERIGROUP
GA380007OtherBCBS
GA000792503JMedicaid
GA380007OtherBCBS
GA93BDWKDMedicare PIN
GAP00069363Medicare PIN