Provider Demographics
NPI:1891875522
Name:DEMOREST, REBECCA A (MD)
Entity Type:Individual
Prefix:
First Name:REBECCA
Middle Name:A
Last Name:DEMOREST
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 1:2716 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2489
Mailing Address - Country:US
Mailing Address - Phone:910-332-3800
Mailing Address - Fax:
Practice Address - Street 1:2716 ASHTON DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2489
Practice Address - Country:US
Practice Address - Phone:910-332-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD0348322080S0010X
CAA1057422080S0010X
NC2011-000012080S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080S0010XAllopathic & Osteopathic PhysiciansPediatricsSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H81471Medicare UPIN