Basic Information
| Provider Information | |||||||||
| NPI: | 1871588376 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEREDITH | ||||||||
| FirstName: | WILBUR | ||||||||
| MiddleName: | RYAN | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 WILMOT DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048610425 | ||||||||
| FaxNumber: | 7048610274 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 WILMOT DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280544048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048610425 | ||||||||
| FaxNumber: | 7048610274 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/12/2005 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 306 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 2413957006 | 01 | CIGNA | OTHER | 890815J | 05 | NC | MEDICAID | 101245 | 01 | WELLNESS | OTHER | 17607 | 01 | WELLPATH | OTHER | 2047532 | 01 | AETNA | OTHER | 4406591 | 01 | AETNA | OTHER | PDN306 | 05 | NC | MEDICAID | 238688 | 01 | MAMSI | OTHER | 561552247002 | 01 | PRUDENTIAL | OTHER |