Healthcare Provider Details

I. General information

NPI: 1629042999
Provider Name (Legal Business Name): JERRY R WILBORN JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2006
Last Update Date: 11/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 JOHNSON FERRY RD NE
ATLANTA GA
30342-1606
US

IV. Provider business mailing address

PO BOX 2968
KENNESAW GA
30156-9117
US

V. Phone/Fax

Practice location:
  • Phone: 404-851-6936
  • Fax:
Mailing address:
  • Phone: 770-779-0015
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number045666
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: