Provider Demographics
NPI:1609172097
Name:POURNIK, HOMAYOUN
Entity Type:Individual
Prefix:
First Name:HOMAYOUN
Middle Name:
Last Name:POURNIK
Suffix:
Gender:M
Credentials:
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 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:517 MOYE BLVD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:NC
Practice Address - Zip Code:27834
Practice Address - Country:US
Practice Address - Phone:252-744-2620
Practice Address - Fax:252-744-3452
Is Sole Proprietor?:No
Enumeration Date:2011-02-01
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA146226204F00000X
NC2018-01729208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCNN3172AOtherMEDICARE
NC19WQUOtherBCBS OF NC
NC1609172097Medicaid