Provider Demographics
NPI:1376597823
Name:DAGENHART, TIMOTHY L (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:L
Last Name:DAGENHART
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:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:704-638-1551
Mailing Address - Fax:704-638-1553
Practice Address - Street 1:1904 JAKE ALEXANDER BLVD W
Practice Address - Street 2:STE 301
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1178
Practice Address - Country:US
Practice Address - Phone:704-638-1551
Practice Address - Fax:704-638-1553
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC38036207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8926738Medicaid
NC2154617DMedicare PIN
NC8926738Medicaid