Provider Demographics
NPI:1932166394
Name:WILBER, RICHARD (MD)
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:WILBER
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 4978
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95352-4978
Mailing Address - Country:US
Mailing Address - Phone:209-575-4575
Mailing Address - Fax:209-575-4598
Practice Address - Street 1:1165 MONTGOMERY DR
Practice Address - Street 2:PATHOLOGY DEPT
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4801
Practice Address - Country:US
Practice Address - Phone:209-575-4575
Practice Address - Fax:209-575-4598
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-28
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34845207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G348450Medicaid
CA00G348450Medicare PIN
CA00G348450Medicaid