Healthcare Provider Details

I. General information

NPI: 1962841460
Provider Name (Legal Business Name): DIABETES ENDOCRINOLOGY & METABOLISM ASSOCIATES, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/18/2013
Last Update Date: 07/30/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4456 CENTRAL AVE
CHARLOTTE NC
28205-5702
US

IV. Provider business mailing address

PO BOX 471947
CHARLOTTE NC
28247-1947
US

V. Phone/Fax

Practice location:
  • Phone: 980-299-0023
  • Fax: 980-299-1002
Mailing address:
  • Phone: 980-299-0023
  • Fax: 980-299-1002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code305R00000X
TaxonomyPreferred Provider Organization
License Number23415
License Number StateSC

VIII. Authorized Official

Name: DR. GODWIN OBINNA UZOMBA
Title or Position: PRESIDENT
Credential: MD
Phone: 980-299-0223