Healthcare Provider Details

I. General information

NPI: 1205206604
Provider Name (Legal Business Name): CAROLINA DEVELOPMENTAL PEDIATRICS PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 12/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 W WILLIAMS ST SUITE 104
APEX NC
27502-3978
US

IV. Provider business mailing address

1001 W WILLIAMS ST SUITE 104
APEX NC
27502-3978
US

V. Phone/Fax

Practice location:
  • Phone: 919-362-5406
  • Fax: 919-362-5409
Mailing address:
  • Phone: 919-362-5406
  • Fax: 919-362-5409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0006X
TaxonomyDevelopmental - Behavioral Pediatrics Physician
License Number200100579
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1285H
Identifier TypeOTHER
Identifier State
Identifier IssuerBCBS
# 2
Identifier891285H
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DR. DANIEL L MORAN
Title or Position: DOCTOR
Credential: M.D.
Phone: 919-362-5406