Basic Information
| Provider Information | |||||||||
| NPI: | 1417295940 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | PRIVATE DIAGNOSTIC CLINIC, PLLC | ||||||||
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| OtherOrganizationName: | DUKE PEDIATRIC DERMATOLOGY @ PATTERSON PLACE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 110566 | ||||||||
| Address2: | |||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277095566 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196204855 | ||||||||
| FaxNumber: | 9196204921 | ||||||||
| Practice Location | |||||||||
| Address1: | 5324 MCFARLAND RD | ||||||||
| Address2: | STE. 410 | ||||||||
| City: | DURHAM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 277076865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9196848111 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/17/2013 | ||||||||
| LastUpdateDate: | 05/18/2022 | ||||||||
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| AuthorizedOfficialLastName: | NEWMAN | ||||||||
| AuthorizedOfficialFirstName: | PAUL | ||||||||
| AuthorizedOfficialMiddleName: | RAYMOND | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR, PDC | ||||||||
| AuthorizedOfficialTelephone: | 9196137652 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 05/18/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207NP0225X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Dermatology | Pediatric Dermatology |
No ID Information.