Provider Demographics
NPI: | 1720255326 |
---|---|
Name: | SOLIC, JOHN MICHAEL (MD) |
Entity Type: | Individual |
Prefix: | |
First Name: | JOHN |
Middle Name: | MICHAEL |
Last Name: | SOLIC |
Suffix: | |
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: | 120 WILLIAM PENN PLZ |
Mailing Address - Street 2: | |
Mailing Address - City: | DURHAM |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 27704-2150 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 919-220-5255 |
Mailing Address - Fax: | 919-313-1276 |
Practice Address - Street 1: | 3100 DURALEIGH RD STE 100 |
Practice Address - Street 2: | |
Practice Address - City: | RALEIGH |
Practice Address - State: | NC |
Practice Address - Zip Code: | 27612-8105 |
Practice Address - Country: | US |
Practice Address - Phone: | 919-788-8797 |
Practice Address - Fax: | 919-788-8798 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2008-05-13 |
Last Update Date: | 2018-03-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 2011-01076 | 207X00000X, 207XX0005X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207XX0005X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No | 207X00000X | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
NC | 2011-01076 | Other | NC MEDICAL LICENSE |
NC | 2011-01076 | Other | NC MEDICAL LICENSE |