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General NPI Number Information
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NPI Number | 1619978285
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Entity Type | Individual
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Provider Name | Personalized Hematology Oncology of Wake Forest, PLLC
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Gender | Male
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Dates
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Enumeration Date | 08/09/2005
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Last Update Date | 02/26/2013
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Provider Practice Location Address
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Address Line | 11635 NORTHPARK DR SUITE 250
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City | WAKE FOREST
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State | NC
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Zip | 27587-6526
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Country | US
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Telephone | 919-825-4637
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Fax | 919-562-0444
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Provider Business Mailing Address
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Address Line | 11635 NORTHPARK DR SUITE#250
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City | WAKE FOREST
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State | NC
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Zip | 27587-6526
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Country | US
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Telephone | 919-825-4637
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Fax | 919-562-0444
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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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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