Provider Demographics
NPI:1164405874
Name:DUBOSE, THOMAS D JR (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:D
Last Name:DUBOSE
Suffix:JR
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27102-0344
Mailing Address - Country:US
Mailing Address - Phone:336-716-2255
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-2255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-28
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200201240207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC132YHOtherBCBS
WV3810002109Medicaid
NC4514540OtherAETNA
SCQ0124CMedicaid
NCC0870OtherMEDCOST
NC801321OtherPARTNERS
VA5881668Medicaid
NC89132YHMedicaid
NCC0870OtherMEDCOST
NC2009810Medicare PIN
NC801321OtherPARTNERS