Provider Demographics
NPI:1679634646
Name:MEADOR, PHILIP DALE JR (MD)
Entity type:Individual
Prefix:DR
First Name:PHILIP
Middle Name:DALE
Last Name:MEADOR
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 1:568 RUIN CREEK RD
Mailing Address - Street 2:SUITE 120
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-2880
Mailing Address - Country:US
Mailing Address - Phone:252-492-2123
Mailing Address - Fax:252-436-0031
Practice Address - Street 1:568 RUIN CREEK RD
Practice Address - Street 2:SUITE 120
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-2880
Practice Address - Country:US
Practice Address - Phone:252-492-2123
Practice Address - Fax:252-436-0031
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC17395207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC58290OtherBCBS OF NC
NC8958290Medicaid
NCC80926Medicare UPIN
NC58290OtherBCBS OF NC