Provider Demographics
NPI:1255471181
Name:MAGOLAN, JEROME J JR (MD)
Entity Type:Individual
Prefix:
First Name:JEROME
Middle Name:J
Last Name:MAGOLAN
Suffix:JR
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 1:3320 EXECUTIVE DR
Mailing Address - Street 2:STE 111
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7445
Mailing Address - Country:US
Mailing Address - Phone:919-876-2427
Mailing Address - Fax:919-850-9234
Practice Address - Street 1:3320 EXECUTIVE DR
Practice Address - Street 2:STE 111
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7445
Practice Address - Country:US
Practice Address - Phone:919-876-2427
Practice Address - Fax:919-850-9234
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC29002174400000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC795372Medicaid
NC208439Medicare ID - Type Unspecified
NCC85283Medicare UPIN
NC180012509OtherRAILROAD MEDICARE
NC561420397OtherTAX ID#
NC795372Medicaid