Provider Demographics
NPI:1932190139
Name:WIMBERLY, CLARENCE WILLIAM JR (MD)
Entity Type:Individual
Prefix:
First Name:CLARENCE
Middle Name:WILLIAM
Last Name:WIMBERLY
Suffix:JR
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 1:201 SIGMA DRIVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7722
Mailing Address - Country:US
Mailing Address - Phone:843-873-1592
Mailing Address - Fax:843-871-2936
Practice Address - Street 1:435 N CEDAR ST
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29483-6407
Practice Address - Country:US
Practice Address - Phone:843-873-1592
Practice Address - Fax:843-871-2936
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-04
Last Update Date:2019-04-17
Deactivation Date:2019-03-29
Deactivation Code:
Reactivation Date:2019-04-17
Provider Licenses
StateLicense IDTaxonomies
SC5740207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCP01396493OtherRR MEDICARE
SC057404Medicaid
SCB91912Medicare UPIN
SC057404Medicaid