Provider Demographics
NPI:1194795831
Name:WILBANKS, JOHN HARRISON (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:HARRISON
Last Name:WILBANKS
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 1:2211 W BRAKER LN
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78758-4031
Mailing Address - Country:US
Mailing Address - Phone:512-334-2686
Mailing Address - Fax:512-623-5290
Practice Address - Street 1:12221 N MOPAC EXPY
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78758
Practice Address - Country:US
Practice Address - Phone:512-334-2700
Practice Address - Fax:512-623-5290
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2013-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE11792085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX136184211Medicaid
TX271989YN57Medicare PIN
E77724Medicare UPIN
TX271989YN56Medicare PIN