Provider Demographics
NPI:1801010145
Name:ALONZO JAMES DAVIS IV MD PHDPC
Entity Type:Organization
Organization Name:ALONZO JAMES DAVIS IV MD PHDPC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ALONZO
Authorized Official - Middle Name:J
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:IV
Authorized Official - Credentials:MD
Authorized Official - Phone:252-726-5767
Mailing Address - Street 1:221A PROFESSIONAL CIR
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-4303
Mailing Address - Country:US
Mailing Address - Phone:252-726-5767
Mailing Address - Fax:252-726-7573
Practice Address - Street 1:221A PROFESSIONAL CIR
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-4303
Practice Address - Country:US
Practice Address - Phone:252-726-5767
Practice Address - Fax:252-726-7573
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-11
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9401169207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927768Medicaid
NC27291OtherBCBS GROUP NUMBER
NC8927768Medicaid