Basic Information
Provider Information | |||||||||
NPI: | 1326217399 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MED MART MEDICAL ASSOCIATES PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 100 S 10TH ST | ||||||||
Address2: |   | ||||||||
City: | LILLINGTON | ||||||||
State: | NC | ||||||||
PostalCode: | 275466690 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9108934111 | ||||||||
FaxNumber: | 9108939850 | ||||||||
Practice Location | |||||||||
Address1: | 7212 GB ALFORD HWY | ||||||||
Address2: |   | ||||||||
City: | HOLLY SPRINGS | ||||||||
State: | NC | ||||||||
PostalCode: | 275407661 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9195521520 | ||||||||
FaxNumber: | 9195528792 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 02/25/2008 | ||||||||
LastUpdateDate: | 02/09/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | REYES | ||||||||
AuthorizedOfficialFirstName: | RODOLFO | ||||||||
AuthorizedOfficialMiddleName: | C | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 9108934111 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | MD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 9500701 | NC | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.