Healthcare Provider Details

I. General information

NPI: 1649343591
Provider Name (Legal Business Name): BRUCE GEORGE WILBUR M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 SAMARITAN DR
SAN JOSE CA
95124-3912
US

IV. Provider business mailing address

2450 SAMARITAN DR
SAN JOSE CA
95124-3912
US

V. Phone/Fax

Practice location:
  • Phone: 408-358-1855
  • Fax: 408-356-4183
Mailing address:
  • Phone: 408-358-1855
  • Fax: 408-356-4183

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberG18447
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: