Basic Information
| Provider Information | |||||||||
| NPI: | 1568444156 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | RESTO | ||||||||
| FirstName: | WILMA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 60447 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282600447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043849113 | ||||||||
| FaxNumber: | 7043847830 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 E TRADE ST | ||||||||
| Address2: | SUITE D-230 | ||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282022404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043847085 | ||||||||
| FaxNumber: | 7043847089 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/18/2005 | ||||||||
| LastUpdateDate: | 02/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 9400130 | NC | N | Allopathic & Osteopathic Physicians | Family Medicine | 207R00000X | 9400130 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 8971293 | 05 | NC | MEDICAID | N00131 | 05 | SC | MEDICAID |