Provider Demographics
NPI:1518955319
Name:DEYOUNG, BARRY R (MD)
Entity Type:Individual
Prefix:
First Name:BARRY
Middle Name:R
Last Name:DEYOUNG
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:MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27157-0001
Mailing Address - Country:US
Mailing Address - Phone:336-716-4195
Mailing Address - Fax:336-716-3202
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:336-716-4195
Practice Address - Fax:336-716-3202
Is Sole Proprietor?:No
Enumeration Date:2005-10-06
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA33078207ZP0101X
NC2013-00575207ZP0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZP0101XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0218479Medicaid
IA1218479Medicaid
IA22079OtherWELLMARK BCBS
NC1518955319Medicaid
IA33932OtherWELLMARK BCBS
NCNCC490AMedicare PIN
G03989Medicare UPIN
IA220029423Medicare PIN
IAP00050272Medicare PIN
IAI9673Medicare PIN
IA22079OtherWELLMARK BCBS