Healthcare Provider Details

I. General information

NPI: 1164536363
Provider Name (Legal Business Name): JOHN C PITTMAN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4505 FAIR MEADOWS LN
RALEIGH NC
27607-6465
US

IV. Provider business mailing address

4505 FAIR MEADOWS LN SUITE 111
RALEIGH NC
27607-6465
US

V. Phone/Fax

Practice location:
  • Phone: 919-571-4391
  • Fax: 919-571-8968
Mailing address:
  • Phone: 919-571-4391
  • Fax: 919-571-8968

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number31614
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: