Provider Demographics
NPI:1790216042
Name:JESSUP, CHARLES KIRK (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:KIRK
Last Name:JESSUP
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 1:1008 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27701-4013
Mailing Address - Country:US
Mailing Address - Phone:914-216-2864
Mailing Address - Fax:
Practice Address - Street 1:1240 HUFFMAN MILL RD
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:NC
Practice Address - Zip Code:27215-8700
Practice Address - Country:US
Practice Address - Phone:336-538-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-27
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00640207P00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine