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General NPI Number Information
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NPI Number | 1376046003
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Entity Type | Organization
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Legal Business Name | DEARK MEDICAL CENTER PLLC
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Dates
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Enumeration Date | 03/08/2018
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Last Update Date | 02/06/2019
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Provider Practice Location Address
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Address Line | 3719 LATROBE DR STE 840
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City | CHARLOTTE
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State | NC
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Zip | 28211-5121
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Country | US
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Telephone | 913-302-1470
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Fax |
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Provider Business Mailing Address
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Address Line | 3719 LATROBE DR STE 840
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City | CHARLOTTE
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State | NC
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Zip | 28211-5121
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Country | US
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Telephone | 913-302-1470
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | EFEMWONKIEKIE WILLIAM IYAMU
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Credential | MD
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Telephone | 913-302-1470
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QC1500X
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Taxonomy Name | Community Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QM1000X
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Taxonomy Name | Migrant Health Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 261QP2300X
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Taxonomy Name | Primary Care Clinic/Center
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 324500000X
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Taxonomy Name | Substance Abuse Rehabilitation Facility
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 2016-01529
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License Number State | NC
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