Basic Information
| Provider Information | |||||||||
| NPI: | 1922365444 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILBURN | ||||||||
| FirstName: | JOSHUA | ||||||||
| MiddleName: | J. | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 119 AMBULANCE DR STE 202 | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301173857 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708388787 | ||||||||
| FaxNumber: | 7708388922 | ||||||||
| Practice Location | |||||||||
| Address1: | 25 W LYON ST | ||||||||
| Address2: | |||||||||
| City: | TALLAPOOSA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 301761288 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7708242800 | ||||||||
| FaxNumber: | 7708242810 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/22/2012 | ||||||||
| LastUpdateDate: | 07/21/2022 | ||||||||
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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 | 207R00000X | 077594 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | PENDING | 05 | GA | MEDICAID |