Provider Demographics
NPI:1134411390
Name:PACE, MARYELLEN DOLAT (MD)
Entity type:Individual
Prefix:
First Name:MARYELLEN
Middle Name:DOLAT
Last Name:PACE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:509 N ELAM AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27403-1157
Mailing Address - Country:US
Mailing Address - Phone:336-274-1114
Mailing Address - Fax:336-274-9638
Practice Address - Street 1:509 N ELAM AVE FL 2
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27403-1157
Practice Address - Country:US
Practice Address - Phone:336-274-1114
Practice Address - Fax:336-274-9638
Is Sole Proprietor?:No
Enumeration Date:2011-05-06
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
NC2019-00623208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program