Provider Demographics
NPI:1770563348
Name:WILBUR, RICHARD J (MD)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:J
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 1:1117 E HALLANDALE BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:HALLANDALE BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33009-4488
Mailing Address - Country:US
Mailing Address - Phone:954-454-6300
Mailing Address - Fax:954-266-4006
Practice Address - Street 1:4050 SHERIDAN STREET
Practice Address - Street 2:STE. D
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3561
Practice Address - Country:US
Practice Address - Phone:954-989-7441
Practice Address - Fax:954-989-7454
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044134207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLME0044134OtherSTATE LICENSE NUMBER
FLME0044134OtherSTATE LICENSE NUMBER
FL02485Medicare ID - Type Unspecified
FLD50536Medicare UPIN