Provider Demographics
NPI:1710924311
Name:MASSENBURG, ALTHEA H (MD)
Entity Type:Individual
Prefix:
First Name:ALTHEA
Middle Name:H
Last Name:MASSENBURG
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 1:5420 WADE PARK BLVD
Mailing Address - Street 2:STE 106
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-4188
Mailing Address - Country:US
Mailing Address - Phone:919-851-2174
Mailing Address - Fax:919-854-7774
Practice Address - Street 1:4003 N ROXBORO ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27704-2119
Practice Address - Country:US
Practice Address - Phone:919-220-3333
Practice Address - Fax:919-220-6317
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC099-00545207Q00000X
NC0099-00545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC129Y5OtherBCBS
NC129Y5OtherBCBS
NC2293703AMedicare ID - Type Unspecified