Provider Demographics
NPI:1538185228
Name:BOYD, DEBORAH DAETWYLER (MD)
Entity type:Individual
Prefix:
First Name:DEBORAH
Middle Name:DAETWYLER
Last Name:BOYD
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:PO BOX 3527
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27895-3527
Mailing Address - Country:US
Mailing Address - Phone:252-399-7557
Mailing Address - Fax:252-399-1324
Practice Address - Street 1:130 GLENDALE DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2770
Practice Address - Country:US
Practice Address - Phone:252-399-7557
Practice Address - Fax:252-399-1324
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC7720208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8917244Medicaid
NC8917244Medicaid
NCC82906Medicare UPIN