Provider Demographics
NPI:1043207749
Name:IRVIN, JOHN D (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:D
Last Name:IRVIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:6407 GREEN ARBOR LN
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-2137
Mailing Address - Country:US
Mailing Address - Phone:910-470-3888
Mailing Address - Fax:
Practice Address - Street 1:4654 LONG BEACH RD SE
Practice Address - Street 2:
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-8799
Practice Address - Country:US
Practice Address - Phone:910-457-9564
Practice Address - Fax:910-457-6744
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC94-01419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC77610OtherMEDCOST
NC8945429Medicaid
NC0128762OtherUNITED HEALTHCARE
NC145G6OtherBCBS OF NC
NCD43178Medicare UPIN
NC2204730DMedicare PIN