Provider Demographics
NPI:1376046003
Name:DEARK MEDICAL CENTER PLLC
Entity Type:Organization
Organization Name:DEARK MEDICAL CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:
Authorized Official - First Name:EFEMWONKIEKIE
Authorized Official - Middle Name:WILLIAM
Authorized Official - Last Name:IYAMU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:913-302-1470
Mailing Address - Street 1:3719 LATROBE DR STE 840
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5121
Mailing Address - Country:US
Mailing Address - Phone:913-302-1470
Mailing Address - Fax:
Practice Address - Street 1:3719 LATROBE DR STE 840
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-5121
Practice Address - Country:US
Practice Address - Phone:913-302-1470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-08
Last Update Date:2019-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2016-01529207R00000X
261QC1500X, 261QM1000X, 261QP2300X, 324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QM1000XAmbulatory Health Care FacilitiesClinic/CenterMigrant Health
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilityGroup - Single Specialty