Provider Demographics
NPI:1780660654
Name:TER POORTEN, JON C (MD)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:C
Last Name:TER POORTEN
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 1:335 PENNY LN
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1221
Mailing Address - Country:US
Mailing Address - Phone:704-784-5901
Mailing Address - Fax:702-721-0413
Practice Address - Street 1:335 PENNY LN
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1221
Practice Address - Country:US
Practice Address - Phone:704-784-5901
Practice Address - Fax:704-721-0413
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2009-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2000-00323207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC70014929OtherMEDICARE RAILROAD
NC89126RRMedicaid
NCH19312Medicare UPIN
NC70014929OtherMEDICARE RAILROAD
NC2280594Medicare ID - Type Unspecified