Provider Demographics
NPI:1558369207
Name:WIMMER, MARK T (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:T
Last Name:WIMMER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 604061
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-4061
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:631 MOCKSVILLE AVE STE 1020
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2731
Practice Address - Country:US
Practice Address - Phone:704-210-7600
Practice Address - Fax:704-210-7601
Is Sole Proprietor?:No
Enumeration Date:2005-07-07
Last Update Date:2022-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9501457207RX0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC900002508OtherRRMEDICARE
NC1193WOtherBC/BS
NC891193WMedicaid
NC1193WOtherBC/BS
NC2270722Medicare PIN