Provider Demographics
NPI:1710206909
Name:JEBAILY, NICHOLAS XAVIER (MD)
Entity Type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:XAVIER
Last Name:JEBAILY
Suffix:
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 1:4444 N 32ND ST STE 175
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85018-3999
Mailing Address - Country:US
Mailing Address - Phone:602-952-0002
Mailing Address - Fax:602-224-9119
Practice Address - Street 1:4444 N 32ND ST STE 175
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85018-3999
Practice Address - Country:US
Practice Address - Phone:602-952-0002
Practice Address - Fax:602-224-9119
Is Sole Proprietor?:No
Enumeration Date:2010-05-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ49154207RC0000X
NC2013-01215207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1710206909Medicaid
SCQ0121SMedicaid
NCNCE018AMedicare PIN