Provider Demographics
NPI:1780679357
Name:EDMISTEN, TIMOTHY DWIGHT (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:DWIGHT
Last Name:EDMISTEN
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 1:965 STATE FARM RD
Mailing Address - Street 2:
Mailing Address - City:BOONE
Mailing Address - State:NC
Mailing Address - Zip Code:28607-4948
Mailing Address - Country:US
Mailing Address - Phone:828-264-2340
Mailing Address - Fax:828-262-0731
Practice Address - Street 1:965 STATE FARM RD
Practice Address - Street 2:
Practice Address - City:BOONE
Practice Address - State:NC
Practice Address - Zip Code:28607-4948
Practice Address - Country:US
Practice Address - Phone:828-264-2340
Practice Address - Fax:828-262-0731
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-20
Last Update Date:2023-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC98008562086S0129X, 208G00000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891227RMedicaid
NC891227RMedicaid
2279582Medicare ID - Type Unspecified