Basic Information
| Provider Information | |||||||||
| NPI: | 1386024446 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILBANKS | ||||||||
| FirstName: | LAURA | ||||||||
| MiddleName: | CONRAD | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CONRAD | ||||||||
| OtherFirstName: | LAURA | ||||||||
| OtherMiddleName: | ELIZABETH | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 169 ASHLEY AVE | ||||||||
| Address2: | ROOM 202 MAIN HOSPITAL, MSC333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437923072 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 169 ASHLEY AVE | ||||||||
| Address2: | ROOM 202 MAIN HOSPITAL, MSC333 | ||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294258905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8437923072 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/04/2015 | ||||||||
| LastUpdateDate: | 03/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 01081878A | IN | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | LL38336 | SC | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.