Healthcare Provider Details

I. General information

NPI: 1114920162
Provider Name (Legal Business Name): JON DUBOSE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 HOSPITAL DR
TARBORO NC
27886-2011
US

IV. Provider business mailing address

111 HOSPITAL DR
TARBORO NC
27886-2011
US

V. Phone/Fax

Practice location:
  • Phone: 252-641-7700
  • Fax: 252-641-7313
Mailing address:
  • Phone: 252-641-7700
  • Fax: 252-641-7313

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200101440
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number87299
License Number StateSC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number200101440
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: