Provider Demographics
NPI:1083673511
Name:DARE MEDICAL ASSOCIATES
Entity type:Organization
Organization Name:DARE MEDICAL ASSOCIATES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:L
Authorized Official - Last Name:HOLTON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:252-473-3478
Mailing Address - Street 1:PO BOX 1045
Mailing Address - Street 2:
Mailing Address - City:MANTEO
Mailing Address - State:NC
Mailing Address - Zip Code:27954-1045
Mailing Address - Country:US
Mailing Address - Phone:252-473-3478
Mailing Address - Fax:252-473-3600
Practice Address - Street 1:604 AMANDA ST
Practice Address - Street 2:
Practice Address - City:MANTEO
Practice Address - State:NC
Practice Address - Zip Code:27954
Practice Address - Country:US
Practice Address - Phone:252-473-3478
Practice Address - Fax:252-473-3600
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-22
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC19609207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8901408Medicaid
NC01408OtherBCBS
=========OtherTRICARE
NC8901408Medicaid
C84556Medicare UPIN