Provider Demographics
NPI:1134354814
Name:MIEDEMA, JAYSON R (MD)
Entity type:Individual
Prefix:
First Name:JAYSON
Middle Name:R
Last Name:MIEDEMA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:410 MARKET ST STE 400
Mailing Address - Street 2:
Mailing Address - City:CHAPEL HILL
Mailing Address - State:NC
Mailing Address - Zip Code:27516-4061
Mailing Address - Country:US
Mailing Address - Phone:984-974-3692
Mailing Address - Fax:984-974-3900
Practice Address - Street 1:410 MARKET ST STE 400
Practice Address - Street 2:DEPARTMENT OF DERMATOLOGY
Practice Address - City:CHAPEL HILL
Practice Address - State:NC
Practice Address - Zip Code:27516-4061
Practice Address - Country:US
Practice Address - Phone:919-966-2485
Practice Address - Fax:919-966-6460
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-25
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2012-00940207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology