Provider Demographics
NPI:1891789756
Name:MERTESDORF, JAMES M (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:M
Last Name:MERTESDORF
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 1:1515 DOCTORS CIR
Mailing Address - Street 2:HANOVER MEDICAL SPECIALISTS
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7403
Mailing Address - Country:US
Mailing Address - Phone:910-763-1219
Mailing Address - Fax:910-763-0291
Practice Address - Street 1:1515 DOCTORS CIR
Practice Address - Street 2:HANOVER MEDICAL SPECIALISTS
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28401-7403
Practice Address - Country:US
Practice Address - Phone:910-763-1219
Practice Address - Fax:910-763-0291
Is Sole Proprietor?:No
Enumeration Date:2005-09-07
Last Update Date:2007-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27826207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8958702Medicaid
NCC85509Medicare UPIN
NC8958702Medicaid