MEDICARE: DR. TIMOTHY D WINGO MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	24057	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1457363178
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TIMOTHY D WINGO MD

Provider Business Mailing Address
First Line	:	3240 SUNSET BLVD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3428
Country	:	US
Telephone Number	:	803-796-4251
Fax Number	:	803-796-4449

Provider Business Practice Location Address
First Line	:	3240 SUNSET BLVD
Second Line	:
City	:	WEST COLUMBIA
State	:	SC
Zip	:	29169-3428
Country	:	US
Telephone Number	:	803-796-4251
Fax Number	:	803-796-4449

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/12/2006
Last Update Date	:	08/29/2012

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