Provider Demographics
NPI:1265457451
Name:BOHMER, MARY KATHRYN WHITTEN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHRYN WHITTEN
Last Name:BOHMER
Suffix:
Gender:F
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7810 PROVIDENCE RD
Practice Address - Street 2:STE 105
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-2954
Practice Address - Country:US
Practice Address - Phone:704-446-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700806207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891135XMedicaid
NC1265457451Medicaid
NC73417OtherMEDCOST
NCP00100794OtherRR MEDICARE
SCN00808Medicaid
SCN00808Medicaid
NC1265457451Medicaid