Provider Demographics
NPI:1427017730
Name:ANDERSON, JAY A (DDS, MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:A
Last Name:ANDERSON
Suffix:
Gender:M
Credentials:DDS, MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:143 W FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-2539
Mailing Address - Country:US
Mailing Address - Phone:919-966-8596
Mailing Address - Fax:919-843-5515
Practice Address - Street 1:101 MANNING DR
Practice Address - Street 2:
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27599-0001
Practice Address - Country:US
Practice Address - Phone:919-966-8596
Practice Address - Fax:919-843-5515
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2012-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC14786207L00000X, 207LP2900X
NC29695207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6911153Medicaid
SCTL5625Medicaid
NC6911153Medicaid
NC204463AMedicare PIN
D26925Medicare UPIN