Basic Information
| Provider Information | |||||||||
| NPI: | 1528002102 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | INGRAM | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | LANE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2004 N LAKESHORE DR | ||||||||
| Address2: | |||||||||
| City: | CHAPEL HILL | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275142024 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9199679883 | ||||||||
| FaxNumber: | 9193508677 | ||||||||
| Practice Location | |||||||||
| Address1: | 3024 NEW BERN AVE | ||||||||
| Address2: | ANDREWS CENTER, SUITE 307 | ||||||||
| City: | RALEIGH | ||||||||
| State: | NC | ||||||||
| PostalCode: | 276101247 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9193508493 | ||||||||
| FaxNumber: | 9193508677 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 19062 | NC | Y | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 8945251 | 05 | NC | MEDICAID |