Healthcare Provider Details

I. General information

NPI: 1114218989
Provider Name (Legal Business Name): MARYANN BUKER WILBUR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2011
Last Update Date: 10/14/2020
Certification Date: 10/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 LATTIMORE RD STE 258
ROCHESTER NY
14620-4155
US

IV. Provider business mailing address

601 ELMWOOD AVE BOX 668
ROCHESTER NY
14642-0001
US

V. Phone/Fax

Practice location:
  • Phone: 585-442-8020
  • Fax: 585-442-8039
Mailing address:
  • Phone: 585-442-8020
  • Fax: 585-442-8039

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number307289
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: