Provider Demographics
NPI:1831294446
Name:LINEBACK, WILBUR GEORGE JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:GEORGE
Last Name:LINEBACK
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 1:2104 W MICHIGAN AVE
Mailing Address - Street 2:
Mailing Address - City:MIDLAND
Mailing Address - State:TX
Mailing Address - Zip Code:79701-5928
Mailing Address - Country:US
Mailing Address - Phone:432-570-9552
Mailing Address - Fax:432-570-9859
Practice Address - Street 1:2104 W MICHIGAN AVE
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5928
Practice Address - Country:US
Practice Address - Phone:432-570-9552
Practice Address - Fax:432-570-9859
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1528174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXG33482Medicare UPIN
TX0086APMedicare ID - Type Unspecified