Healthcare Provider Details

I. General information

NPI: 1972547305
Provider Name (Legal Business Name): JOHN EASTER WIMMER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 GREEN VALLEY RD SUITE 210
GREENSBORO NC
27408-7730
US

IV. Provider business mailing address

628 GREEN VALLEY RD SUITE 210
GREENSBORO NC
27408-7730
US

V. Phone/Fax

Practice location:
  • Phone: 336-478-1016
  • Fax: 336-851-1737
Mailing address:
  • Phone: 336-478-1016
  • Fax: 336-851-1737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25465
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number25465
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: