Provider Demographics
NPI:1639240617
Name:WITHERS, SYDNOR TERRY JR (MD)
Entity Type:Individual
Prefix:
First Name:SYDNOR
Middle Name:TERRY
Last Name:WITHERS
Suffix:JR
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 598
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28480
Mailing Address - Country:US
Mailing Address - Phone:910-791-5426
Mailing Address - Fax:910-799-2433
Practice Address - Street 1:5058 WRIGHTSVILLE AVE
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28405
Practice Address - Country:US
Practice Address - Phone:910-791-5426
Practice Address - Fax:910-799-2433
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2013-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5902268Medicaid
NC201718DMedicare PIN
NC5902268Medicaid