Provider Demographics
NPI:1629134127
Name:PICKETT, JOHN ROBERT
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:PICKETT
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:R
Other - Last Name:PICKETT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:410 S TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27803-1837
Mailing Address - Country:US
Mailing Address - Phone:252-442-5752
Mailing Address - Fax:252-446-1338
Practice Address - Street 1:9201 COUNTY LINE RD.
Practice Address - Street 2:
Practice Address - City:SHARPSBURG
Practice Address - State:NC
Practice Address - Zip Code:27878
Practice Address - Country:US
Practice Address - Phone:252-446-4455
Practice Address - Fax:252-446-1338
Is Sole Proprietor?:No
Enumeration Date:2006-12-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200000114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA89130F0Medicaid
PAHO8213Medicare UPIN
PA89130F0Medicaid