Provider Demographics
NPI:1376629113
Name:VISSER, SCOTT WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:SCOTT
Middle Name:WILLIAM
Last Name:VISSER
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 1:4141 SHIPYARD BLVD
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403
Mailing Address - Country:US
Mailing Address - Phone:910-792-9925
Mailing Address - Fax:910-792-9926
Practice Address - Street 1:4141 SHIPYARD BLVD
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403
Practice Address - Country:US
Practice Address - Phone:910-792-9925
Practice Address - Fax:910-792-9926
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2010-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0031674207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985064Medicaid
C86926Medicare UPIN
NC8985064Medicaid
NC2318323Medicare ID - Type UnspecifiedGROUP#