Provider Demographics
NPI:1508823949
Name:FAILLACE, DEON F (MD)
Entity Type:Individual
Prefix:
First Name:DEON
Middle Name:F
Last Name:FAILLACE
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:PO BOX 61811
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27715-1811
Mailing Address - Country:US
Mailing Address - Phone:919-544-6318
Mailing Address - Fax:919-544-6336
Practice Address - Street 1:2041 VALLEYGATE DR
Practice Address - Street 2:SUITE 202-A
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304
Practice Address - Country:US
Practice Address - Phone:910-485-6277
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2018-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC318092083P0011X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCP00352202OtherMEDICARE-RAILROAD
NC31041OtherBCBS-NC INDIVIDUAL
NC7931041Medicaid
NC31041OtherBCBS-NC INDIVIDUAL
NCP00352202OtherMEDICARE-RAILROAD