Provider Demographics
NPI:1972596567
Name:WILLBRANDT, BARRY (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:
Last Name:WILLBRANDT
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 1:12057 DELMAR PLAZA
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39503-4308
Mailing Address - Country:US
Mailing Address - Phone:228-867-5185
Mailing Address - Fax:228-867-5184
Practice Address - Street 1:12057 DELMAR PLAZA
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39503
Practice Address - Country:US
Practice Address - Phone:228-897-5185
Practice Address - Fax:228-897-5184
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2018-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18038174400000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
A99442Medicare UPIN