Provider Demographics
NPI:1245660406
Name:BALA, WILBUR (MD)
Entity type:Individual
Prefix:
First Name:WILBUR
Middle Name:
Last Name:BALA
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:LAWTEY CORRECTIONAL INSTITUTION
Mailing Address - Street 2:7819 NW 228 ST.
Mailing Address - City:RAIFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32026
Mailing Address - Country:US
Mailing Address - Phone:904-782-2318
Mailing Address - Fax:904-782-2011
Practice Address - Street 1:LAWTEY CORRECTIONAL INSTITUTION
Practice Address - Street 2:7819 NW 228 ST.
Practice Address - City:RAIFORD
Practice Address - State:FL
Practice Address - Zip Code:32026-0001
Practice Address - Country:US
Practice Address - Phone:904-782-2318
Practice Address - Fax:904-782-2011
Is Sole Proprietor?:No
Enumeration Date:2013-11-25
Last Update Date:2013-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME27246208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice