Basic Information
| Provider Information | |||||||||
| NPI: | 1073713053 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DUNN FOOT & ANKLE CENTER, P.A. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 303 TILGHMAN DR | ||||||||
| Address2: | |||||||||
| City: | DUNN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283345524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108923338 | ||||||||
| FaxNumber: | 9108922706 | ||||||||
| Practice Location | |||||||||
| Address1: | 303 TILGHMAN DR | ||||||||
| Address2: | |||||||||
| City: | DUNN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283345524 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108923338 | ||||||||
| FaxNumber: | 9108922706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 10/29/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BASS | ||||||||
| AuthorizedOfficialFirstName: | ELIZABETH | ||||||||
| AuthorizedOfficialMiddleName: | G. | ||||||||
| AuthorizedOfficialTitleorPosition: | PODIATRIST | ||||||||
| AuthorizedOfficialTelephone: | 9108923338 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | D.P.M. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | 223 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
| ID | Type | State | Issuer | Description | 890141F | 05 | NC | MEDICAID | 0141F | 01 | NC | BCBS | OTHER |