Individual
DANA POINT
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
4222 LONG BEACH RD SE, SOUTHPORT, NC 28461-8627
(910) 763-2510
Mailing address
PO BOX 936857, ATLANTA, GA 31193-6857
(910) 662-8765
(910) 362-9123
Taxonomy
Speciality
Code
Description
License number
State
208800000X
Urology Physician
Primary
2016-00414
NC
Other
Enumeration date
06/08/2011
Last updated
11/03/2021
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