Basic Information
| Provider Information | |||||||||
| NPI: | 1508823949 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FAILLACE | ||||||||
| FirstName: | DEON | ||||||||
| MiddleName: | F | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 61811 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277151811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195446318 | ||||||||
| FaxNumber: | 9195446336 | ||||||||
| Practice Location | |||||||||
| Address1: | 2041 VALLEYGATE DR | ||||||||
| Address2: | SUITE 202-A | ||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28304 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104856277 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2006 | ||||||||
| LastUpdateDate: | 07/31/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0011X | 31809 | NC | N | Allopathic & Osteopathic Physicians | Preventive Medicine | Undersea and Hyperbaric Medicine | 208600000X | 31809 | NC | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | P00352202 | 01 | NC | MEDICARE-RAILROAD | OTHER | 31041 | 01 | NC | BCBS-NC INDIVIDUAL | OTHER | 7931041 | 05 | NC | MEDICAID |