Provider Demographics
NPI:1457383135
Name:VISSER, PHILIP A (MD)
Entity Type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:A
Last Name:VISSER
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-446-1255
Mailing Address - Fax:704-446-1276
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1255
Practice Address - Fax:704-446-1276
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2014-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC27643208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8985096Medicaid
NC1457383135Medicaid
SCN27643Medicaid
NC85096OtherNCBCBS
NC1457383135Medicaid
NC85096OtherNCBCBS
NCNCJ480AMedicare PIN
NC203083CMedicare PIN
SCN27643Medicaid