Provider Demographics
NPI:1801868906
Name:WIMMER, MICHAEL ERNEST (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ERNEST
Last Name:WIMMER
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 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-735-2900
Mailing Address - Fax:
Practice Address - Street 1:1250 8TH AVE STE 600
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-4121
Practice Address - Country:US
Practice Address - Phone:817-702-7144
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-02
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXH4803208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX125518404Medicaid
TX848660OtherBCBS
TXP00978119OtherRAILROAD MEDICARE
TX125518406Medicaid
TX8CX897OtherBCBS
TX250003321Medicare PIN
TX848660Medicare PIN
TXP00978119OtherRAILROAD MEDICARE
TX125518404Medicaid