Provider Demographics
NPI:1922052026
Name:MIMS, WILLIAM WALTON JR (MD)
Entity Type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:WALTON
Last Name:MIMS
Suffix:JR
Gender:M
Credentials:MD
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Mailing Address - Street 1:1175 COOK RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29118-8201
Mailing Address - Country:US
Mailing Address - Phone:803-534-4611
Mailing Address - Fax:803-534-7269
Practice Address - Street 1:1175 COOK RD
Practice Address - Street 2:SUITE 310
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29118-8201
Practice Address - Country:US
Practice Address - Phone:803-534-4611
Practice Address - Fax:803-534-7269
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-22
Last Update Date:2007-07-08
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
SC5227208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCPA6252Medicaid
SCD99222Medicare UPIN
SCPA6252Medicaid