Provider Demographics
NPI:1669456752
Name:IRETON, CANDACE LYNN (MD)
Entity Type:Individual
Prefix:
First Name:CANDACE
Middle Name:LYNN
Last Name:IRETON
Suffix:
Gender:F
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:PO BOX 602373
Mailing Address - Street 2:MISSION MEDICAL ASSOCIATES
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2373
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:310 LONG SHOALS RD
Practice Address - Street 2:STE 310
Practice Address - City:ARDEN
Practice Address - State:NC
Practice Address - Zip Code:28704-8794
Practice Address - Country:US
Practice Address - Phone:828-274-6610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2017-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-079379207Q00000X
NC2013-01398207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2261850Medicaid
OHIR4057919Medicare PIN
OHH45379Medicare UPIN
OHIR4057915Medicare ID - Type Unspecified