Provider Demographics
NPI:1821298522
Name:JOHN, TRENT EVERARD DIRK (MD)
Entity Type:Individual
Prefix:
First Name:TRENT
Middle Name:EVERARD DIRK
Last Name:JOHN
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-1570
Mailing Address - Fax:704-384-1534
Practice Address - Street 1:8401 MEDICAL PLAZA DR
Practice Address - Street 2:SUITE 220
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-8797
Practice Address - Country:US
Practice Address - Phone:704-384-1570
Practice Address - Fax:704-384-1534
Is Sole Proprietor?:No
Enumeration Date:2007-07-20
Last Update Date:2020-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCTL29878208000000X
NC2014-01643208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics