Provider Demographics
NPI:1053679944
Name:PERSONALIZED HEMATOLOGY-ONCOLOGY OF WAKE FOREST PLLC
Entity Type:Organization
Organization Name:PERSONALIZED HEMATOLOGY-ONCOLOGY OF WAKE FOREST PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LUMINITA
Authorized Official - Middle Name:
Authorized Official - Last Name:CASTILLOS
Authorized Official - Suffix:
Authorized Official - Credentials:PHD, MBA
Authorized Official - Phone:919-556-2907
Mailing Address - Street 1:11635 NORTH PARK DRIVE
Mailing Address - Street 2:SUITE 250
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-6298
Mailing Address - Country:US
Mailing Address - Phone:919-825-4637
Mailing Address - Fax:919-435-1060
Practice Address - Street 1:11635 NORTH PARK DRIVE
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-6298
Practice Address - Country:US
Practice Address - Phone:919-556-2907
Practice Address - Fax:919-435-1060
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-04-27
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400833207R00000X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & OncologyGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89137UCMedicaid
NC137UCOtherBCBS
NCH11669Medicare UPIN
NC89137UCMedicaid