Provider Demographics
NPI:1588863161
Name:WHITE-DUNHAM, MAYISHA (MD)
Entity type:Individual
Prefix:
First Name:MAYISHA
Middle Name:
Last Name:WHITE-DUNHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:170 WHITMORE COVE CT
Mailing Address - Street 2:
Mailing Address - City:CLEMMONS
Mailing Address - State:NC
Mailing Address - Zip Code:27012-8883
Mailing Address - Country:US
Mailing Address - Phone:252-258-0480
Mailing Address - Fax:
Practice Address - Street 1:170 WHITMORE COVE CT
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8883
Practice Address - Country:US
Practice Address - Phone:252-258-0480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-13
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00186207RA0401X, 208100000X
GA90862208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910806Medicaid
P00810246OtherMAYISHA DUNHAM PTAN
NC5910806Medicaid