Provider Demographics
NPI:1285624031
Name:FISHBURNE, CARY NELSON DAVIS JR (MD)
Entity type:Individual
Prefix:DR
First Name:CARY
Middle Name:NELSON DAVIS
Last Name:FISHBURNE
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 1:295A MIDLAND PKWY STE 130
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29485-5901
Mailing Address - Country:US
Mailing Address - Phone:843-873-9690
Mailing Address - Fax:843-875-0368
Practice Address - Street 1:10220 PROSPERITY PARK DR STE 300
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28269-1106
Practice Address - Country:US
Practice Address - Phone:704-316-1120
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9601608207V00000X
SC40796207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891332YMedicaid
H82169Medicare UPIN
NCNC6521AMedicare PIN
NC2012487DMedicare PIN
NC2012487EMedicare PIN