Basic Information
| Provider Information | |||||||||
| NPI: | 1942311378 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILBUR | ||||||||
| FirstName: | STANLEY | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 12230 LIONESS WAY | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801345603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206449355 | ||||||||
| FaxNumber: | 7205231654 | ||||||||
| Practice Location | |||||||||
| Address1: | 12230 LIONESS WAY | ||||||||
| Address2: | |||||||||
| City: | PARKER | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801345603 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7206449355 | ||||||||
| FaxNumber: | 7205231654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/31/2006 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | G72614 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00G726140 | 05 | CA | MEDICAID |