Healthcare Provider Details

I. General information

NPI: 1417941956
Provider Name (Legal Business Name): PAUL C. WHITESIDES JR. M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/09/2005
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 EMERSON BAY RD SUITE 102
CAROLINA SHORES NC
28467-2498
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 910-579-8363
  • Fax: 910-579-8306
Mailing address:
  • Phone: 910-579-8363
  • Fax: 910-579-8306

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number25968
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: