NPIMap

Individual provider Active NPI

Theodore R Wissink, MD

  • Family Medicine Physician
  • South Burlington, VT
National Provider Identifier
1124193503
Registry record updated Dec 22, 2025
On this page

Key facts

NPPES NPI Registry
Primary specialty
Family Medicine PhysicianTaxonomy code 207Q00000X
License
042.0019084 Issued in VT
Practice address
118 Tilley Dr Ste 201
South Burlington, VT 05403-4450
Phone
(802) 847-5550
Fax
(802) 847-3646
NPI assigned
Nov 21, 2006
Sex
Male
Sole proprietor
No

NPPES NPI Registry

Updated by the provider on Dec 22, 2025

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 2

Specialty (taxonomy)CodeLicenseStatePrimary
Family Medicine Physician 207Q00000X 017817 ME
Family Medicine Physician 207Q00000X 042.0019084 VT Primary

Addresses

Primary practice location

118 Tilley Dr Ste 201
South Burlington, VT 05403-4450

Mailing address

111 Colchester Ave
Burlington, VT 05401-1473
Phone (802) 847-0000

Other practice location 1

272 Congress St
Portland, ME 04101
Phone (207) 874-2466

Other identifiers 2

IdentifierTypeStateIssuer
432952299MedicaidME
30207877MedicaidNH

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in ME, VT2 enrollments
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 2

Enrollment IDStateProvider typePAC IDDetails
I20080812000033 ME Practitioner - Family Practice 5890869770 Reassigns benefits to 5 organizations
I20251215003654 VT Practitioner - Family Practice 5890869770 Reassigns benefits to 1 organization

Care Compare profile

Medicare Care Compare
Specialty
Family Practice
Education
University of Minnesota Medical School, 2004
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Telehealth
Offers telehealth services
Group practices
MainehealthGroup PAC ID 7517860588, shared by 31 NPIs, 2,616 clinicians

Practice addresses (Care Compare)

1 S Prospect St
Burlington, VT 05401-3456
Phone (802) 847-0000

111 Colchester Ave
Burlington, VT 05401-1473
Phone (802) 847-0000

118 Tilley Dr
South Burlington, VT 05403-4450

22 Bramhall St
Portland, ME 04102-3134
Phone (207) 885-9905

272 Congress St
Portland, ME 04101-3637
Phone (207) 874-2466

5 Bucknam Rd
Falmouth, ME 04105-1209

Hospital & facility affiliations

Procedures performed for Medicare patients

ProcedureNumber of procedures
Removal of skin lesions1-10
Removal or shaving of skin growth1-10
Skin biopsy1-10

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Enrolled
Credentials
Doctor of Medicine

State licenses

LicenseStateTypeSpecialty
017817MEMDFamily Medicine Physician
042.0019084VTMDFamily Medicine Physician

Practice roles

OrganizationSpecialtyStatusNew patients
Maine Medical Partners CurrentSince Jan 1, 2014 Accepting new patients
University of Vermont Medical Center Inc Family Medicine CurrentSince Dec 1, 2025 Accepting new patients
Mainehealth Current Accepting new patients
Mainehealth CurrentSince Aug 1, 2008 Accepting new patients
Maine Medical Partners Family Medicine CurrentSince Nov 10, 2019 Accepting new patients
Mainehealth Family Medicine CurrentSince Aug 1, 2008 Accepting new patients
Maine Medical Partners CurrentSince Jan 1, 2014 Accepting new patients
Maine Medical Partners CurrentSince Jan 1, 2014 Accepting new patients
Mainehealth CurrentSince Aug 1, 2008 Accepting new patients
Fletcher Allen Health Care Inc PastSince Dec 28, 2025 Accepting new patients
Mainehealth Family Medicine Past Accepting new patients

Locations

5 Bucknam Rd
Ste 2C
Portland, ME 04105
Phone (207) 781-1500

22 Bramhall St
Portland, ME 04102
Phone (207) 662-2179

272 Congress St
Portland, ME 04101
Phone (207) 874-2466

3 Glen Cove Dr
#3
Rockport, ME 04856
Phone (207) 301-5400

96 Campus Dr
Ste 2B
Scarborough, ME 04074
Phone (207) 883-3491

39 Wallace Ave
South Portland, ME 04106
Phone (207) 761-0650

1 Harnois Ave
Ste 2
Westbrook, ME 04092
Phone (207) 661-3400

1 Harnois Ave
Ste 1A
Westbrook, ME 04092
Phone (207) 662-1360

584 Roosevelt Trl
Windham, ME 04062
Phone (207) 892-3216

111 Colchester Ave
Burlington, VT 05401
Phone (802) 656-2415

1 S Prospect St
Burlington, VT 05401
Phone (802) 847-4531

118 Tilley Dr
Ste 201
South Burlington, VT 05403
Phone (802) 847-5550

Interoperability endpoints

  • Direct secure messaging: twissink5100@direct.mmc.mainehealth.org

Organizations & group practices 11

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships and National Provider Directory roles.

Hospital & facility affiliations 37

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

View all 37

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1164067200000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1766361600000",
    "number": "1124193503",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "111 COLCHESTER AVE",
            "city": "BURLINGTON",
            "state": "VT",
            "postal_code": "054011473",
            "telephone_number": "802-847-0000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "118 TILLEY DR STE 201",
            "city": "SOUTH BURLINGTON",
            "state": "VT",
            "postal_code": "054034450",
            "telephone_number": "802-847-5550",
            "fax_number": "802-847-3646"
        }
    ],
    "practiceLocations": [
        {
            "address_1": "272 Congress St",
            "address_purpose": "LOCATION",
            "city": "Portland",
            "state": "ME",
            "postal_code": "04101",
            "country_code": "US",
            "telephone_number": "207-874-2466",
            "fax_number": "207-774-4625",
            "country_name": "United States",
            "address_type": "DOM"
        }
    ],
    "basic": {
        "last_name": "WISSINK",
        "first_name": "THEODORE",
        "middle_name": "R",
        "name_prefix": "Dr.",
        "credential": "MD",
        "sole_proprietor": "NO",
        "sex": "M",
        "enumeration_date": "2006-11-21",
        "last_updated": "2025-12-22",
        "certification_date": "2025-12-22",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "ME",
            "license": "017817",
            "primary": false
        },
        {
            "code": "207Q00000X",
            "taxonomy_group": "",
            "desc": "Family Medicine",
            "state": "VT",
            "license": "042.0019084",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "432952299",
            "state": "ME"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "30207877",
            "state": "NH"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in South Burlington, VT

Sources for this page

Verify at the official NPI Registry.