Provider Demographics
NPI:1427060565
Name:WILHELM, BRYAN (DPM)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:
Last Name:WILHELM
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 SW NANCY WAY STE 2
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97702-3256
Mailing Address - Country:US
Mailing Address - Phone:541-385-7129
Mailing Address - Fax:541-385-7138
Practice Address - Street 1:1510 SW NANCY WAY STE 2
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97702-3256
Practice Address - Country:US
Practice Address - Phone:541-385-7129
Practice Address - Fax:541-385-7138
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2011-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORDP00214213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR865318004OtherBLUE CROSS
OR014352Medicaid
OR20-2456582OtherTAX ID
OR20-2456582OtherTAX ID
OR014352Medicaid
OR5869870001Medicare NSC