Healthcare Provider Details

I. General information

NPI: 1104885979
Provider Name (Legal Business Name): DIRK HAMP M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2006
Last Update Date: 07/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 CAPITAL BLVD
WAKE FOREST NC
27587-4513
US

IV. Provider business mailing address

260 HORIZON DR
RALEIGH NC
27615-4922
US

V. Phone/Fax

Practice location:
  • Phone: 919-488-4094
  • Fax: 919-488-4096
Mailing address:
  • Phone: 919-488-0015
  • Fax: 919-277-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200300044
License Number StateNC

VII. Legacy identifiers

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

# 1
Identifier89133UH
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: