Provider Demographics
NPI:1700142551
Name:JABBOUR, JAD
Entity Type:Individual
Prefix:
First Name:JAD
Middle Name:
Last Name:JABBOUR
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6035 FAIRVIEW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3256
Mailing Address - Country:US
Mailing Address - Phone:704-295-3000
Mailing Address - Fax:
Practice Address - Street 1:6035 FAIRVIEW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210
Practice Address - Country:US
Practice Address - Phone:704-295-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-05
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NC2018-00516207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCPENDINGMedicaid