1619925724 NPI number — DR. CHARLES VAN SIKES JR. O.D.

Table of content: DR. CHARLES VAN SIKES JR. O.D. (NPI 1619925724)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619925724 NPI number — DR. CHARLES VAN SIKES JR. O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
SIKES
Provider First Name:
CHARLES
Provider Middle Name:
VAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
JR.
Provider Credential Text:
O.D.
Provider Gender Code:
M

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:
1619925724
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/25/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
120 JOHNSON ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROADWAY
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27505-9503
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
919-258-9203
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1225 CARTHAGE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SANFORD
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27330-8984
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
919-774-3556
Provider Business Practice Location Address Fax Number:
919-774-7356
Provider Enumeration Date:
05/04/2006

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: 152W00000X , with the licence number:  0997 , 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: 410000229 . This is a "RAILROAD MDCR LILLINGTON" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 0158090001 . This is a "PALMETTO LILLINGTON" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 8909827 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7909832 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09832 . This is a "BCBS OF NC" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 09832 . This is a "BCBS LILLINGTON" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".
  • Identifier: 410014665 . This is a "RAILROAD MEDICARE SANFORD" identifier , issued by the state of ( NC ) . This identifiers is of the category "OTHER".




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