Provider Demographics
NPI:1073956637
Name:HARBERTSON, BRYCE ALAN (MD)
Entity Type:Individual
Prefix:
First Name:BRYCE
Middle Name:ALAN
Last Name:HARBERTSON
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 WAKE FOREST RD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7317
Mailing Address - Country:US
Mailing Address - Phone:919-954-3624
Mailing Address - Fax:
Practice Address - Street 1:3400 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7317
Practice Address - Country:US
Practice Address - Phone:919-954-3624
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-04-14
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012645072085R0202X
390200000X
NC2019-001112085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1073956637Medicaid