Provider Demographics
NPI:1366884686
Name:WILLBANKS, BRYAN JACOB (IDC)
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:JACOB
Last Name:WILLBANKS
Suffix:
Gender:M
Credentials:IDC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3155 SALMON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92124-3641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3155 SALMON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3641
Practice Address - Country:US
Practice Address - Phone:843-475-5341
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-28
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
No246RP1900XTechnologists, Technicians & Other Technical Service ProvidersTechnician, PathologyPhlebotomy
No146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No171000000XOther Service ProvidersMilitary Health Care Provider
No174H00000XOther Service ProvidersHealth Educator
No247000000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Health Information