Basic Information
| Provider Information | |||||||||
| NPI: | 1487921045 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILBERG | ||||||||
| FirstName: | BRADLEY | ||||||||
| MiddleName: | ALEXANDER | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | BCABA | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 453 KING ST | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216335511 | ||||||||
| FaxNumber: | 3212087441 | ||||||||
| Practice Location | |||||||||
| Address1: | 453 KING ST | ||||||||
| Address2: | |||||||||
| City: | COCOA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329227621 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216335511 | ||||||||
| FaxNumber: | 3212087441 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/28/2011 | ||||||||
| LastUpdateDate: | 04/06/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/06/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | RBT-16-17842 | Y |
No ID Information.