Provider Demographics
NPI:1497051080
Name:WIMMER, MATTHEW SCOTT (DO)
Entity Type:Individual
Prefix:DR
First Name:MATTHEW
Middle Name:SCOTT
Last Name:WIMMER
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52 MEDICAL GROUP
Mailing Address - Street 2:UNIT 3690
Mailing Address - City:APO
Mailing Address - State:AE
Mailing Address - Zip Code:09126-3690
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:52 MEDICAL GROUP
Practice Address - Street 2:UNIT 3690
Practice Address - City:APO
Practice Address - State:AE
Practice Address - Zip Code:09126-3690
Practice Address - Country:US
Practice Address - Phone:314-452-8363
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-01-31
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02004052A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program