Basic Information
| Provider Information | |||||||||
| NPI: | 1346217031 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DUNLAP | ||||||||
| FirstName: | GLENN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 4839 | ||||||||
| Address2: | |||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283744839 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197519120 | ||||||||
| FaxNumber: | 9197519170 | ||||||||
| Practice Location | |||||||||
| Address1: | 6 REGIONAL DR | ||||||||
| Address2: | SUITE A | ||||||||
| City: | PINEHURST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283748850 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9197519120 | ||||||||
| FaxNumber: | 9197519170 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2006 | ||||||||
| LastUpdateDate: | 07/09/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | X | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | 286 | NC | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 890805K | 05 | NC | MEDICAID | 08062 | 01 | NC | BCBS INDIVIDUAL | OTHER |