Healthcare Provider Details

I. General information

NPI: 1255898094
Provider Name (Legal Business Name): OLD WELL MEDICINE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/28/2019
Last Update Date: 02/17/2024
Certification Date: 02/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5322 NC HIGHWAY 55 STE 102B
DURHAM NC
27713-7816
US

IV. Provider business mailing address

964 HIGH HOUSE RD STE 3217
CARY NC
27513-3574
US

V. Phone/Fax

Practice location:
  • Phone: 919-944-4404
  • Fax:
Mailing address:
  • Phone: 833-433-7100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code183500000X
TaxonomyPharmacist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State
# 8
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: DR. AMIT A PATEL
Title or Position: MANAGER
Credential: MD
Phone: 919-495-6777