Provider Demographics
NPI:1447412945
Name:WERTHEIMER, MICHAEL L (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:L
Last Name:WERTHEIMER
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 1:726 GOODMAN RD E # B
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9530
Mailing Address - Country:US
Mailing Address - Phone:662-349-1959
Mailing Address - Fax:662-349-0424
Practice Address - Street 1:726 GOODMAN RD E # B
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9530
Practice Address - Country:US
Practice Address - Phone:662-349-1959
Practice Address - Fax:662-349-0424
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-26
Last Update Date:2012-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS21002207W00000X
TNMD0000045703207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSXXXXX5420OtherBCBS
TN4277943OtherBCBS TN
MS302I185247Medicare PIN
TN4277943OtherBCBS TN