Healthcare Provider Details

I. General information

NPI: 1336179969
Provider Name (Legal Business Name): JONATHAN DANIEL SHOFFNER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 01/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 CRESCENT GREEN
CARY NC
27511
US

IV. Provider business mailing address

1001 CRESCENT GRN
CARY NC
27518-8101
US

V. Phone/Fax

Practice location:
  • Phone: 919-467-3211
  • Fax: 919-467-5315
Mailing address:
  • Phone: 919-235-3042
  • Fax: 919-235-3094

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number200100462
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier89128V6
Identifier TypeMEDICAID
Identifier StateNC
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: