Provider Demographics
NPI:1538260211
Name:HUMAYUN, DABIRUDDIN (MD)
Entity type:Individual
Prefix:DR
First Name:DABIRUDDIN
Middle Name:
Last Name:HUMAYUN
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:PO BOX 15133
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27704-0133
Mailing Address - Country:US
Mailing Address - Phone:919-477-5345
Mailing Address - Fax:919-477-5474
Practice Address - Street 1:3830 BLUE RIDGE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27612-4319
Practice Address - Country:US
Practice Address - Phone:919-781-4900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200400517207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89138G3Medicaid
NC200400517OtherSTATE LICENSE
NC138G3OtherBLUECROSS BLUESHIELDS
NCBH5827879OtherDEA
NCBH5827879OtherDEA