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General NPI Number Information
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NPI Number | 1053679944
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Entity Type | Organization
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Legal Business Name | PERSONALIZED HEMATOLOGY-ONCOLOGY OF WAKE FOREST PLLC
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Dates
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Enumeration Date | 04/27/2012
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Last Update Date | 07/05/2012
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Provider Practice Location Address
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Address Line | 11635 NORTH PARK DRIVE
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City | WAKE FOREST
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State | NC
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Zip | 27587-6298
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Country | US
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Telephone | 919-556-2907
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Fax | 919-435-1060
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Provider Business Mailing Address
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Address Line | 11635 NORTH PARK DRIVE SUITE 250
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City | WAKE FOREST
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State | NC
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Zip | 27587-6298
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Country | US
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Telephone | 919-825-4637
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Fax | 919-435-1060
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Authorized Official
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Title or Position | PRACTICE MANAGER
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Name | MRS. LUMINITA CASTILLOS
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Credential | PHD, MBA
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Telephone | 919-556-2907
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 200400833
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License Number State | NC
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Taxonomy #2
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Taxonomy Code | 207RH0003X
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Taxonomy Name | Hematology & Oncology Physician
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License Number | 200400833
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License Number State | NC
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