Provider Demographics
NPI:1457680183
Name:JOHN, JISHA (MD)
Entity Type:Individual
Prefix:DR
First Name:JISHA
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
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 603949
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-3949
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:2304 WESVILL CT
Practice Address - Street 2:STE 240
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-2973
Practice Address - Country:US
Practice Address - Phone:919-571-1567
Practice Address - Fax:919-782-1472
Is Sole Proprietor?:No
Enumeration Date:2009-12-08
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.125970207RI0200X
NC2020-03323207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1457680183Medicaid