Provider Demographics
NPI:1790767382
Name:CARBONE, DOMINICK JOHN JR (MD)
Entity Type:Individual
Prefix:
First Name:DOMINICK
Middle Name:JOHN
Last Name:CARBONE
Suffix:JR
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 1:200 JOHNSON RIDGE MEDICAL PARK
Mailing Address - Street 2:
Mailing Address - City:ELKIN
Mailing Address - State:NC
Mailing Address - Zip Code:28621-2443
Mailing Address - Country:US
Mailing Address - Phone:336-526-0040
Mailing Address - Fax:336-526-0043
Practice Address - Street 1:200 JOHNSON RIDGE MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:ELKIN
Practice Address - State:NC
Practice Address - Zip Code:28621-2443
Practice Address - Country:US
Practice Address - Phone:336-526-0040
Practice Address - Fax:336-526-0043
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700498208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2238674BMedicare ID - Type Unspecified
G48723Medicare UPIN