Healthcare Provider Details

I. General information

NPI: 1578692703
Provider Name (Legal Business Name): PINEHURST FOOT SPECIALIST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 05/31/2024
Certification Date: 05/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

325 PAGE RD BLDG 3
PINEHURST NC
28374-8850
US

IV. Provider business mailing address

PO BOX 4839
PINEHURST NC
28374-4839
US

V. Phone/Fax

Practice location:
  • Phone: 919-751-9120
  • Fax: 919-751-9170
Mailing address:
  • Phone: 919-751-9120
  • Fax: 919-751-9170

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP1100X
TaxonomyPodiatric Clinic/Center
License Number286
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier2431909J
Identifier TypeOTHER
Identifier StateNC
Identifier IssuerMEDICARE INDIVIDUAL PROVIDER NUMBER
# 2
Identifier890805K
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name: DR. GLENN DUNLAP
Title or Position: OWNER
Credential: DPM
Phone: 919-751-9120