1104945864 NPI number — DIEGO FERNANDO PABON M.D.

Table of content: DIEGO FERNANDO PABON M.D. (NPI 1104945864)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104945864 NPI number — DIEGO FERNANDO PABON M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
PABON
Provider First Name:
DIEGO
Provider Middle Name:
FERNANDO
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104945864
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/25/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2915 LYNDHURST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINSTON SALEM
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
27103-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
336-765-5221
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1041 KIRKPATRICK RD STE 150
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BURLINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
27215-8068
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
336-538-1888
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/27/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208600000X , with the licence number:  2012-01261 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208600000X , with the licence number: LL 27894 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)