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NPI Code Detail

MEDICARE: DANA POINT MD

MEDICARE: DANA POINT 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
1208800000XUrology Physician2016-00414NC

General Provider Information

NPI Number : 1659665560
Entity Type Code : Individual
Provider Name (Legal Business Name) : DANA POINT MD
Provider Business Mailing Address
First Line : PO BOX 936857
Second Line :
City : ATLANTA
State : GA
Zip : 31193-6857
Country : US
Telephone Number : 910-662-8765
Fax Number : 910-362-9123
Provider Business Practice Location Address
First Line : 4222 LONG BEACH RD SE
Second Line :
City : SOUTHPORT
State : NC
Zip : 28461-8627
Country : US
Telephone Number : 910-763-2510
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 06/08/2011
Last Update Date : 11/03/2021

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Directions to “ DANA POINT MD” Practice Location

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