Provider Demographics
NPI:1740283043
Name:STRADER, WILBUR J (MD)
Entity type:Individual
Prefix:
First Name:WILBUR
Middle Name:J
Last Name:STRADER
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:PO BOX 9520
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79995-9520
Mailing Address - Country:US
Mailing Address - Phone:915-533-5486
Mailing Address - Fax:915-533-9602
Practice Address - Street 1:1201 E SCHUSTER AVE
Practice Address - Street 2:BLDG 7
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-4660
Practice Address - Country:US
Practice Address - Phone:915-533-5486
Practice Address - Fax:915-533-9602
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2012-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD7693207RE0101X, 207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXZ00BA817Medicaid
TX00BA81Medicare PIN
TXZ00BA817Medicaid