Provider Demographics
NPI: | 1619085545 |
---|---|
Name: | DE MARIA, ALFRED (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | ALFRED |
Middle Name: | |
Last Name: | DE MARIA |
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: | 2511 DELANEY AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WILMINGTON |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28403-6003 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 910-772-9202 |
Mailing Address - Fax: | 866-345-8963 |
Practice Address - Street 1: | 1222 MEDICAL CENTER DR |
Practice Address - Street 2: | ATTN: CREDENTIALING |
Practice Address - City: | WILMINGTON |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28401-7307 |
Practice Address - Country: | US |
Practice Address - Phone: | 910-341-3383 |
Practice Address - Fax: | 910-341-3321 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-08-29 |
Last Update Date: | 2014-06-06 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 21641 | 2084N0400X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 8928311 | Medicaid | |
NC | 28311 | Other | BCBS NC |
NC | 130013806 | Other | RAILROAD MEDICARE |
NC | H13608 | Medicare UPIN | |
NC | 2180586G | Medicare PIN | |
NC | 2180586D | Medicare PIN |