Provider Demographics
NPI:1568444156
Name:RESTO, WILMA (MD)
Entity Type:Individual
Prefix:DR
First Name:WILMA
Middle Name:
Last Name:RESTO
Suffix:
Gender:F
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:704-384-9113
Mailing Address - Fax:704-384-7830
Practice Address - Street 1:210 E TRADE ST
Practice Address - Street 2:SUITE D-230
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28202-2404
Practice Address - Country:US
Practice Address - Phone:704-384-7085
Practice Address - Fax:704-384-7089
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2013-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400130207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8971293Medicaid
SCN00131Medicaid
NCF35979Medicare UPIN
NC8971293Medicaid