Provider Demographics
NPI:1770561532
Name:WILBOURN, DARIN KEITH (MD)
Entity type:Individual
Prefix:
First Name:DARIN
Middle Name:KEITH
Last Name:WILBOURN
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 1:410 W PERSHING BLVD
Mailing Address - Street 2:
Mailing Address - City:NORTH LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72114-2146
Mailing Address - Country:US
Mailing Address - Phone:501-771-0674
Mailing Address - Fax:501-753-4174
Practice Address - Street 1:410 W PERSHING BLVD
Practice Address - Street 2:
Practice Address - City:NORTH LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72114-2146
Practice Address - Country:US
Practice Address - Phone:501-771-0674
Practice Address - Fax:501-753-4174
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-03
Last Update Date:2014-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARC8478208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5J834Medicare ID - Type Unspecified
G10497Medicare UPIN