Provider Demographics
NPI:1750337325
Name:FERNANDO, JAY GRAYSON (MD)
Entity type:Individual
Prefix:
First Name:JAY
Middle Name:GRAYSON
Last Name:FERNANDO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:7615 COLONY RD
Mailing Address - Street 2:STE 115
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-5017
Mailing Address - Country:US
Mailing Address - Phone:704-626-6812
Mailing Address - Fax:704-626-6824
Practice Address - Street 1:7615 COLONY RD
Practice Address - Street 2:STE 115
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-5017
Practice Address - Country:US
Practice Address - Phone:704-626-6812
Practice Address - Fax:704-626-6824
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC99011722084A0401X, 207R00000X, 207RA0401X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No2084A0401XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Medicine
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC891235UMedicaid
NC891235UMedicaid
NCH06770Medicare UPIN