Provider Demographics
NPI:1104945864
Name:PABON, DIEGO FERNANDO (MD)
Entity type:Individual
Prefix:
First Name:DIEGO
Middle Name:FERNANDO
Last Name:PABON
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 1:2915 LYNDHURST AVE
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-4005
Mailing Address - Country:US
Mailing Address - Phone:336-765-5221
Mailing Address - Fax:
Practice Address - Street 1:1041 KIRKPATRICK RD STE 150
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8068
Practice Address - Country:US
Practice Address - Phone:336-538-1888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-27
Last Update Date:2021-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-01261208600000X
SCLL 27894208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery