1508823949 NPI number — DEON F FAILLACE MD

Table of content: DEON F FAILLACE MD (NPI 1508823949)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1508823949 NPI number — DEON F FAILLACE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
FAILLACE
Provider First Name:
DEON
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1508823949
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/31/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 61811
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DURHAM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27715-1811
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-544-6318
Provider Business Mailing Address Fax Number:
919-544-6336

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2041 VALLEYGATE DR
Provider Second Line Business Practice Location Address:
SUITE 202-A
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28304
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
910-485-6277
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2083P0011X , with the licence number:  31809 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: 31809 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: P00352202 . This is a "MEDICARE-RAILROAD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 31041 . This is a "BCBS-NC INDIVIDUAL" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 7931041 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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