Provider Demographics
NPI:1326000316
Name:NEALE, WIRT (MD)
Entity Type:Individual
Prefix:
First Name:WIRT
Middle Name:
Last Name:NEALE
Suffix:
Gender:M
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-7840
Mailing Address - Fax:704-316-0508
Practice Address - Street 1:1315 EAST BLVD
Practice Address - Street 2:SUITE 280
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5975
Practice Address - Country:US
Practice Address - Phone:704-384-1866
Practice Address - Fax:704-384-1867
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2008-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC16797208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8961972Medicaid
NC8961972Medicaid