Provider Demographics
NPI:1477549160
Name:IREDALE, JOHN RICHARD (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:RICHARD
Last Name:IREDALE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4119 CAPITOL ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-2153
Mailing Address - Country:US
Mailing Address - Phone:919-477-9333
Mailing Address - Fax:919-477-9389
Practice Address - Street 1:4119 CAPITOL ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2153
Practice Address - Country:US
Practice Address - Phone:919-477-0333
Practice Address - Fax:919-477-9389
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2011-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC51213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC08092OtherBCBS OF NC PROVIDER NUMBE
NC8908092Medicaid
NC243153Medicare PIN
T64104Medicare UPIN