Provider Demographics
NPI:1700971363
Name:DEHOLL, J. DAVID JR (MD)
Entity Type:Individual
Prefix:
First Name:J.
Middle Name:DAVID
Last Name:DEHOLL
Suffix:JR
Gender:M
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 63314
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28263-3314
Mailing Address - Country:US
Mailing Address - Phone:828-696-1312
Mailing Address - Fax:
Practice Address - Street 1:1216 6TH AVE W
Practice Address - Street 2:
Practice Address - City:HENDERSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28739-3301
Practice Address - Country:US
Practice Address - Phone:828-692-6262
Practice Address - Fax:828-692-5858
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2013-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9700526208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2238261COtherMEDICARE PTAN
NC891049JMedicaid
NC891049JMedicaid