Basic Information
| Provider Information | |||||||||
| NPI: | 1114152337 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DABIRUDDIN M HUMAYUN MD, PLLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 15133 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277040133 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9194775345 | ||||||||
| FaxNumber: | 9194775474 | ||||||||
| Practice Location | |||||||||
| Address1: | 3830 BLUE RIDGE RD | ||||||||
| Address2: | |||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276124319 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197814900 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2009 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| AuthorizedOfficialLastName: | HUMAYUN | ||||||||
| AuthorizedOfficialFirstName: | DABIRUDDIN | ||||||||
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| AuthorizedOfficialTitleorPosition: | MD | ||||||||
| AuthorizedOfficialTelephone: | 9197814900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | NC | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 02DQU | 01 | NC | BCBS OF NC | OTHER | 89138G3 | 05 | NC | MEDICAID |