Provider Demographics
NPI:1104051812
Name:WILLBERG, BRIAN JAMES
Entity type:Individual
Prefix:
First Name:BRIAN
Middle Name:JAMES
Last Name:WILLBERG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 17
Mailing Address - Street 2:BOX 134
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09214-9998
Mailing Address - Country:US
Mailing Address - Phone:49267-895-2244
Mailing Address - Fax:
Practice Address - Street 1:PSC 17
Practice Address - Street 2:BOX 134
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09214-9998
Practice Address - Country:US
Practice Address - Phone:49267-895-2244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-26
Last Update Date:2009-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians