Provider Demographics
NPI:1386745800
Name:WILBUR, CARLY W (MD)
Entity type:Individual
Prefix:
First Name:CARLY
Middle Name:W
Last Name:WILBUR
Suffix:
Gender:F
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 74606
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44194-0689
Mailing Address - Country:US
Mailing Address - Phone:216-991-4180
Mailing Address - Fax:216-991-7329
Practice Address - Street 1:3461 WARRENSVILLE CENTER RD
Practice Address - Street 2:
Practice Address - City:SHAKER HTS
Practice Address - State:OH
Practice Address - Zip Code:44122-5260
Practice Address - Country:US
Practice Address - Phone:216-383-0100
Practice Address - Fax:216-383-6481
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2012-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35083155208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2439427Medicaid
OHH091020Medicare PIN