Provider Demographics
NPI:1356455059
Name:LAFAYETTE CLINIC, PA
Entity Type:Organization
Organization Name:LAFAYETTE CLINIC, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:WHETSELL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-323-1322
Mailing Address - Street 1:PO BOX 43905
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28309-3905
Mailing Address - Country:US
Mailing Address - Phone:910-323-1322
Mailing Address - Fax:910-323-1510
Practice Address - Street 1:2125 VALLEYGATE DR
Practice Address - Street 2:SUITE 201
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-3753
Practice Address - Country:US
Practice Address - Phone:910-323-1322
Practice Address - Fax:910-323-1510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-18
Last Update Date:2008-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatologyGroup - Multi-Specialty
No2080P0201XAllopathic & Osteopathic PhysiciansPediatricsPediatric Allergy/ImmunologyGroup - Multi-Specialty
No2080P0214XAllopathic & Osteopathic PhysiciansPediatricsPediatric PulmonologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CN6121OtherRAILROAD MEDICARE
NC890138GMedicaid
0138GOtherBLUE CROSS BLUE SHIELD
NC890138GMedicaid