Healthcare Provider Details

I. General information

NPI: 1790767382
Provider Name (Legal Business Name): DOMINICK JOHN CARBONE JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/18/2005
Last Update Date: 11/03/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 JOHNSON RIDGE MEDICAL PARK
ELKIN NC
28621-2443
US

IV. Provider business mailing address

200 JOHNSON RIDGE MEDICAL PARK
ELKIN NC
28621-2443
US

V. Phone/Fax

Practice location:
  • Phone: 336-526-0040
  • Fax: 336-526-0043
Mailing address:
  • Phone: 336-526-0040
  • Fax: 336-526-0043

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number9700498
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: