Provider Demographics
NPI:1760484638
Name:WILBERS, RAYMOND H (MD)
Entity Type:Individual
Prefix:DR
First Name:RAYMOND
Middle Name:H
Last Name:WILBERS
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 1:625 E SUMMIT ST
Mailing Address - Street 2:
Mailing Address - City:MEXICO
Mailing Address - State:MO
Mailing Address - Zip Code:65265-3294
Mailing Address - Country:US
Mailing Address - Phone:573-581-2030
Mailing Address - Fax:573-581-7675
Practice Address - Street 1:625 E SUMMIT ST
Practice Address - Street 2:
Practice Address - City:MEXICO
Practice Address - State:MO
Practice Address - Zip Code:65265-3294
Practice Address - Country:US
Practice Address - Phone:573-581-2030
Practice Address - Fax:573-581-7675
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-11
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO29147174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200426203Medicaid
MOA13279Medicare UPIN
MO200426203Medicaid
MO263969Medicare Oscar/Certification