Provider Demographics
NPI:1942338538
Name:CAROLINA PODIATRY CENTER PLLC
Entity Type:Organization
Organization Name:CAROLINA PODIATRY CENTER PLLC
Other - Org Name:WILLIAM J. JOHNCOCK DPM
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:JESSE
Authorized Official - Last Name:JOHNCOCK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:828-327-3029
Mailing Address - Street 1:36 14TH AVE NE
Mailing Address - Street 2:SUITE 102
Mailing Address - City:HICKORY
Mailing Address - State:NC
Mailing Address - Zip Code:28601-2581
Mailing Address - Country:US
Mailing Address - Phone:828-327-3029
Mailing Address - Fax:828-327-3181
Practice Address - Street 1:36 14TH AVE NE
Practice Address - Street 2:SUITE 102
Practice Address - City:HICKORY
Practice Address - State:NC
Practice Address - Zip Code:28601-2581
Practice Address - Country:US
Practice Address - Phone:828-327-3029
Practice Address - Fax:828-327-3181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2012-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC348213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890808NMedicaid
NC0808NOtherBCBS NC NUMBER
NC890808NMedicaid
NC890808NMedicaid