Provider Demographics
NPI:1972639854
Name:TONI WYMER, M.D. LTD
Entity Type:Organization
Organization Name:TONI WYMER, M.D. LTD
Other - Org Name:ANTOINETTE WYMER M.D.
Other - Org Type:Other Name
Authorized Official - Title/Position:ITS PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ANTOINETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:WYMER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:336-774-0290
Mailing Address - Street 1:201 EXECUTIVE PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-1503
Mailing Address - Country:US
Mailing Address - Phone:336-774-9000
Mailing Address - Fax:336-774-9012
Practice Address - Street 1:201 EXECUTIVE PARK BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1503
Practice Address - Country:US
Practice Address - Phone:336-774-0920
Practice Address - Fax:336-774-9012
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-26
Last Update Date:2011-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC33772207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC33772OtherSTATE LICENSE NUMBER
NC33772OtherSTATE LICENSE NUMBER
NC2141013CMedicare PIN