MEDICARE: MELVIN DUBOSE MEDLOCK JR. 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	208600000X	Surgery Physician	2015-01793	NC
2	208600000X	Surgery Physician	058287	GA

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	NCO905A	OTHER	NC	MEDICARE PTAN

General Provider Information

NPI Number	:	1467455493
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MELVIN DUBOSE MEDLOCK JR. MD

Provider Business Mailing Address
First Line	:	5221 PARAMOUNT PKWY STE 220
Second Line	:
City	:	MORRISVILLE
State	:	NC
Zip	:	27560-5490
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2934 N ELM ST STE E
Second Line	:
City	:	LUMBERTON
State	:	NC
Zip	:	28358-2987
Country	:	US
Telephone Number	:	910-739-0022
Fax Number	:	910-739-0079

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

Provider Enumeration Date	:	05/23/2005
Last Update Date	:	03/01/2024

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