Provider Demographics
NPI:1649343591
Name:WILBUR, BRUCE GEORGE (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:GEORGE
Last Name:WILBUR
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 1:2450 SAMARITAN DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-3912
Mailing Address - Country:US
Mailing Address - Phone:408-358-1855
Mailing Address - Fax:408-356-4183
Practice Address - Street 1:2450 SAMARITAN DR
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-3912
Practice Address - Country:US
Practice Address - Phone:408-358-1855
Practice Address - Fax:408-356-4183
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG18447174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA89293Medicare UPIN