Provider Demographics
NPI:1790781649
Name:WILLGRUBER, SEAN TIMOTHY (MD)
Entity Type:Individual
Prefix:DR
First Name:SEAN
Middle Name:TIMOTHY
Last Name:WILLGRUBER
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 1:201 PARK ST
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42101-1759
Mailing Address - Country:US
Mailing Address - Phone:270-780-2497
Mailing Address - Fax:270-783-0454
Practice Address - Street 1:201 PARK ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42101-1759
Practice Address - Country:US
Practice Address - Phone:270-781-5111
Practice Address - Fax:270-783-3779
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-24
Last Update Date:2015-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY323262085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
5151643OtherAETNA
KY000000191881OtherANTHEM
KY64323264Medicaid
5151643OtherAETNA
5151643OtherAETNA