Provider Demographics
NPI:1275538449
Name:RALSTON, JEFFREY JOHN (DO)
Entity Type:Individual
Prefix:DR
First Name:JEFFREY
Middle Name:JOHN
Last Name:RALSTON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 221249
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28222-1249
Mailing Address - Country:US
Mailing Address - Phone:704-332-1291
Mailing Address - Fax:704-332-5206
Practice Address - Street 1:3623 LATROBE DR STE 216
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-2117
Practice Address - Country:US
Practice Address - Phone:704-332-1291
Practice Address - Fax:704-926-1832
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2020-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2004005782085R0202X
NC2004-00578207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1275538449Medicaid
NC89137J0Medicaid
NCI10756Medicare UPIN
NC1275538449Medicaid