MEDICARE: DR. JOHN D IRVIN MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	94-01419	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	77610	OTHER	NC	MEDCOST
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	0128762	OTHER	NC	UNITED HEALTHCARE
4	145G6	OTHER	NC	BCBS OF NC

General Provider Information

NPI Number	:	1043207749
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN D IRVIN MD

Provider Business Mailing Address
First Line	:	6407 GREEN ARBOR LN
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28409-2137
Country	:	US
Telephone Number	:	910-470-3888
Fax Number	:

Provider Business Practice Location Address
First Line	:	4654 LONG BEACH RD SE
Second Line	:
City	:	SOUTHPORT
State	:	NC
Zip	:	28461-8799
Country	:	US
Telephone Number	:	910-457-9564
Fax Number	:	910-457-6744

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/29/2005
Last Update Date	:	03/04/2014

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