Healthcare Provider Details

I. General information

NPI: 1659665560
Provider Name (Legal Business Name): DANA POINT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/08/2011
Last Update Date: 11/03/2021
Certification Date: 11/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4222 LONG BEACH RD SE
SOUTHPORT NC
28461-8627
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-2510
  • Fax:
Mailing address:
  • Phone: 910-662-8765
  • Fax: 910-362-9123

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number2016-00414
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: