Provider Demographics
NPI:1770591406
Name:PADRTA, JERRY JR (MD)
Entity type:Individual
Prefix:
First Name:JERRY
Middle Name:
Last Name:PADRTA
Suffix:JR
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 YADKIN ST
Practice Address - Street 2:SUITE 203
Practice Address - City:ALBEMARLE
Practice Address - State:NC
Practice Address - Zip Code:28001-3449
Practice Address - Country:US
Practice Address - Phone:980-323-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-05
Last Update Date:2019-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-00230208600000X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1255735312Medicaid
NC148Y6OtherBCBS
FL250740400Medicaid
NC5909284Medicaid
NC5909284Medicaid
NC1255735312Medicaid
NCNCL496AMedicare PIN
NC2022079Medicare PIN