Provider Demographics
NPI:1063599587
Name:NIFONG, TED JAMES (MD)
Entity type:Individual
Prefix:DR
First Name:TED
Middle Name:JAMES
Last Name:NIFONG
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:5350 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9174
Mailing Address - Country:US
Mailing Address - Phone:336-784-0505
Mailing Address - Fax:336-784-5031
Practice Address - Street 1:5350 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9174
Practice Address - Country:US
Practice Address - Phone:336-784-0505
Practice Address - Fax:336-784-5031
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2015-02-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC32817207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1063599587OtherNPI
NC8962677Medicaid
NC1063599587OtherNPI