Provider Demographics
NPI:1871588376
Name:MEREDITH, WILBUR RYAN (DPM)
Entity type:Individual
Prefix:DR
First Name:WILBUR
Middle Name:RYAN
Last Name:MEREDITH
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:251 WILMOT DR
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054-4048
Mailing Address - Country:US
Mailing Address - Phone:704-861-0425
Mailing Address - Fax:704-861-0274
Practice Address - Street 1:251 WILMOT DR
Practice Address - Street 2:
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054-4048
Practice Address - Country:US
Practice Address - Phone:704-861-0425
Practice Address - Fax:704-861-0274
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC306213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
2413957006OtherCIGNA
NC890815JMedicaid
101245OtherWELLNESS
17607OtherWELLPATH
2047532OtherAETNA
4406591OtherAETNA
NCPDN306Medicaid
238688OtherMAMSI
561552247002OtherPRUDENTIAL
NC890815JMedicaid
2413957006OtherCIGNA
238688OtherMAMSI