Provider Demographics
NPI:1285895292
Name:UPHAM, TREVOR CHRISTOPHER (MD)
Entity type:Individual
Prefix:
First Name:TREVOR
Middle Name:CHRISTOPHER
Last Name:UPHAM
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 1:2920 HIGHWOODS BLVD
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-0010
Mailing Address - Country:US
Mailing Address - Phone:877-498-4490
Mailing Address - Fax:
Practice Address - Street 1:3000 NEW BERN AVE
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1231
Practice Address - Country:US
Practice Address - Phone:919-231-6333
Practice Address - Fax:919-231-6334
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-23
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA136241208600000X
NC2017-00587208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1285895292Medicaid