Provider Demographics
NPI:1154310043
Name:MIMS, JACQUELINE HEDER (MD)
Entity Type:Individual
Prefix:DR
First Name:JACQUELINE
Middle Name:HEDER
Last Name:MIMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:MARIE
Other - Last Name:HEDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2927 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON-SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4005
Mailing Address - Country:US
Mailing Address - Phone:336-765-9350
Mailing Address - Fax:336-760-4255
Practice Address - Street 1:2927 LYNDHURST AVE
Practice Address - Street 2:
Practice Address - City:WINSTON-SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-4005
Practice Address - Country:US
Practice Address - Phone:336-765-9350
Practice Address - Fax:336-760-4255
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9800639207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891144YMedicaid
NC1144YOtherBCBS
NC2257879Medicare ID - Type Unspecified
NC1144YOtherBCBS
NC891144YMedicaid
NC2257879CMedicare PIN