Basic Information
| Provider Information | |||||||||
| NPI: | 1639172315 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PANG | ||||||||
| FirstName: | CLARITO | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 LIBERTY HILL RD | ||||||||
| Address2: | |||||||||
| City: | LUMBERTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283582446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107393318 | ||||||||
| FaxNumber: | 9106713600 | ||||||||
| Practice Location | |||||||||
| Address1: | 1708A OWEN DR | ||||||||
| Address2: | |||||||||
| City: | FAYETTEVILLE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 283043419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103077330 | ||||||||
| FaxNumber: | 9103077334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 04/07/2014 | ||||||||
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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 | 208000000X | 32160 | NC | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 8965126 | 05 | NC | MEDICAID |