Healthcare Provider Details

I. General information

NPI: 1912970815
Provider Name (Legal Business Name): KEITH LYNDON MCCORMICK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/10/2006
Last Update Date: 05/31/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2047 VALLEYGATE DRIVE
FAYETTEVILLE NC
28304-3688
US

IV. Provider business mailing address

2047 VALLEYGATE DRIVE
FAYETTEVILLE NC
28304-3688
US

V. Phone/Fax

Practice location:
  • Phone: 910-485-3937
  • Fax: 910-221-3672
Mailing address:
  • Phone: 910-485-3937
  • Fax: 910-221-3672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number9501600
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207WX0110X
TaxonomyPediatric Ophthalmology and Strabismus Specialist Physician Physician
License Number9501600
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: