Provider Demographics
NPI:1114213162
Name:WILFORD, RUSSELL RAYMOND JR (MD)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:RAYMOND
Last Name:WILFORD
Suffix:JR
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 68
Mailing Address - Street 2:
Mailing Address - City:POLLOCKSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28573-0068
Mailing Address - Country:US
Mailing Address - Phone:252-633-1010
Mailing Address - Fax:252-224-3071
Practice Address - Street 1:137 MEDICAL LN
Practice Address - Street 2:
Practice Address - City:POLLOCKSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28573-8200
Practice Address - Country:US
Practice Address - Phone:252-633-1010
Practice Address - Fax:252-224-3071
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2025-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2014-01345207R00000X, 208M00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist