Provider Demographics
NPI:1770650764
Name:WILBOURN, SHELBY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:SHELBY
Middle Name:LYNN
Last Name:WILBOURN
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 1:1600 S ANDREWS AVE
Mailing Address - Street 2:SUITE 323 WEST WING
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33316-2510
Mailing Address - Country:US
Mailing Address - Phone:954-355-5110
Mailing Address - Fax:954-355-4919
Practice Address - Street 1:1600 S ANDREWS AVE
Practice Address - Street 2:SUITE 323 WEST WING
Practice Address - City:FORT LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33316-2510
Practice Address - Country:US
Practice Address - Phone:954-355-5110
Practice Address - Fax:954-355-4919
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2010-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ME016025207V00000X
FLME106484207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MEE71297Medicare UPIN