Basic Information
| Provider Information | |||||||||
| NPI: | 1811985302 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILBUR | ||||||||
| FirstName: | PERRY | ||||||||
| MiddleName: | LEE | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 CHILDRENS WAY # 844 | ||||||||
| Address2: | |||||||||
| City: | LITTLE ROCK | ||||||||
| State: | AR | ||||||||
| PostalCode: | 722023500 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5013642090 | ||||||||
| FaxNumber: | 5013643929 | ||||||||
| Practice Location | |||||||||
| Address1: | 2601 GENE GEORGE BLVD | ||||||||
| Address2: | |||||||||
| City: | SPRINGDALE | ||||||||
| State: | AR | ||||||||
| PostalCode: | 72762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4797256880 | ||||||||
| FaxNumber: | 4797256582 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/10/2005 | ||||||||
| LastUpdateDate: | 06/21/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | C-7167 | AR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 115794001 | 05 | AR | MEDICAID | 157490000 | 01 | AR | QUALCHOICE | OTHER | 53356 | 01 | AR | AR BLUE CROSS BLUE SHIELD | OTHER | 122523002 | 05 | AR | MEDICAID |