Healthcare Provider Details

I. General information

NPI: 1477549160
Provider Name (Legal Business Name): JOHN RICHARD IREDALE D.P.M.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 05/04/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4119 CAPITOL ST
DURHAM NC
27704-2153
US

IV. Provider business mailing address

4119 CAPITOL ST
DURHAM NC
27704-2153
US

V. Phone/Fax

Practice location:
  • Phone: 919-477-0333
  • Fax: 919-477-9389
Mailing address:
  • Phone: 919-477-9333
  • Fax: 919-477-9389

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number51
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: