Provider Demographics
NPI:1417976234
Name:ANDERSON, JACK D
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:D
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:
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 601067
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1067
Mailing Address - Country:US
Mailing Address - Phone:704-667-4150
Mailing Address - Fax:704-752-7040
Practice Address - Street 1:7030 PINEVILLE MATTHEWS RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8298
Practice Address - Country:US
Practice Address - Phone:704-667-4150
Practice Address - Fax:704-752-7040
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2013-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC30586208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN30586Medicaid
NC11152OtherBCBS
NC8911152Medicaid
NC11152OtherBCBS
NC8911152Medicaid