Basic Information
| Provider Information | |||||||||
| NPI: | 1720063175 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FELDMAN | ||||||||
| FirstName: | STEVEN | ||||||||
| MiddleName: | RICHARD | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4618 COUNTRY CLUB RD | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043520 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367163926 | ||||||||
| FaxNumber: | 3367169258 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/08/2005 | ||||||||
| LastUpdateDate: | 07/28/2015 | ||||||||
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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 | 207N00000X | 31811 | NC | Y | Allopathic & Osteopathic Physicians | Dermatology | 207ND0900X | 31811 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | Dermatopathology | 207NS0135X | 31811 | NC | N | Allopathic & Osteopathic Physicians | Dermatology | Procedural Dermatology |
ID Information
| ID | Type | State | Issuer | Description | 2002110000 | 05 | WV | MEDICAID | 31516 | 01 | BCBS | OTHER | 63997 | 01 | MEDCOST | OTHER | Q31811 | 05 | SC | MEDICAID | 5940168 | 05 | VA | MEDICAID | 4514 | 01 | PARTNERS | OTHER | 5869085 | 01 | AETNA | OTHER | 8931516 | 05 | NC | MEDICAID |