Provider Demographics
NPI:1073583555
Name:CRAIN, JACK LEE (MD)
Entity Type:Individual
Prefix:DR
First Name:JACK
Middle Name:LEE
Last Name:CRAIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1524 E MOREHEAD ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28207-1606
Mailing Address - Country:US
Mailing Address - Phone:704-343-4452
Mailing Address - Fax:704-343-3428
Practice Address - Street 1:1524 E MOREHEAD ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1606
Practice Address - Country:US
Practice Address - Phone:704-343-4452
Practice Address - Fax:704-343-3428
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-01-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC200001202683OtherPHYS PRIVILEGE LICENSE
NC28480OtherMEDICAL BOARD LICENSE
NCAC4048371OtherDEA NUMBER
NC200001202683OtherPHYS PRIVILEGE LICENSE