Provider Demographics
NPI:1154688455
Name:LENFESTEY, MARY WINDHAM (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:WINDHAM
Last Name:LENFESTEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELIZABETH
Other - Last Name:WINDHAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834-4300
Practice Address - Country:US
Practice Address - Phone:252-744-2335
Practice Address - Fax:252-744-3811
Is Sole Proprietor?:No
Enumeration Date:2012-04-12
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME123430208000000X
NC2018-009922080P0206X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No2080P0206XAllopathic & Osteopathic PhysiciansPediatricsPediatric Gastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1154688455Medicaid
NC19YMYOtherBCBS OF NC
NCNN30240322OtherMEDICARE