Basic Information
| Provider Information | |||||||||
| NPI: | 1538260211 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HUMAYUN | ||||||||
| FirstName: | DABIRUDDIN | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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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 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/26/2006 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 200400517 | NC | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 89138G3 | 05 | NC | MEDICAID | 200400517 | 01 | NC | STATE LICENSE | OTHER | 138G3 | 01 | NC | BLUECROSS BLUESHIELDS | OTHER | BH5827879 | 01 | NC | DEA | OTHER |