Provider Demographics
NPI:1407143100
Name:NEIMAT, MARK MATTHEW (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MATTHEW
Last Name:NEIMAT
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 428
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:WY
Mailing Address - Zip Code:83001-0428
Mailing Address - Country:US
Mailing Address - Phone:307-733-3636
Mailing Address - Fax:888-329-5701
Practice Address - Street 1:625 E BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:WY
Practice Address - Zip Code:83001-8642
Practice Address - Country:US
Practice Address - Phone:307-733-3636
Practice Address - Fax:888-329-5701
Is Sole Proprietor?:No
Enumeration Date:2011-07-01
Last Update Date:2023-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY10289A207R00000X
UT13244411-1205207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY142001100Medicaid