Healthcare Provider Details

I. General information

NPI: 1669713590
Provider Name (Legal Business Name): PRIVATE DIAGNOSTIC CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2013
Last Update Date: 07/11/2022
Certification Date: 07/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1821 HILLANDALE RD STE. 25A
DURHAM NC
27705-2659
US

IV. Provider business mailing address

PO BOX 110566
DURHAM NC
27709-5566
US

V. Phone/Fax

Practice location:
  • Phone: 919-620-7305
  • Fax:
Mailing address:
  • Phone: 919-620-4855
  • Fax: 919-620-4921

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number
License Number State

VIII. Authorized Official

Name: PAUL R NEWMAN
Title or Position: EXECUTIVE DIRECTOR, PDC
Credential:
Phone: 919-613-7652