Healthcare Provider Details

I. General information

NPI: 1417966680
Provider Name (Legal Business Name): C WILSON WESBROOK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2006
Last Update Date: 07/16/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3311 E MURDOCK ST
WICHITA KS
67208-3054
US

IV. Provider business mailing address

PO BOX 8035
WICHITA KS
67208-0035
US

V. Phone/Fax

Practice location:
  • Phone: 316-689-9234
  • Fax: 316-689-9720
Mailing address:
  • Phone: 316-689-9135
  • Fax: 316-689-9102

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License Number16239
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: