Provider Demographics
NPI:1790758613
Name:WILBUR, BENJAMIN STUART (MD)
Entity Type:Individual
Prefix:DR
First Name:BENJAMIN
Middle Name:STUART
Last Name:WILBUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12762 LIMONITE AVE
Mailing Address - Street 2:#3E-235
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-4208
Mailing Address - Country:US
Mailing Address - Phone:951-427-0001
Mailing Address - Fax:909-483-1063
Practice Address - Street 1:1155 NORTH VERMONT AVE
Practice Address - Street 2:SUITE 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90029-1728
Practice Address - Country:US
Practice Address - Phone:323-664-1814
Practice Address - Fax:323-663-1723
Is Sole Proprietor?:No
Enumeration Date:2006-02-10
Last Update Date:2012-09-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA92956208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
I49938Medicare UPIN
CAA92956Medicare PIN