Healthcare Provider Details

I. General information

NPI: 1396705042
Provider Name (Legal Business Name): SOUTH CHARLOTTE PEDIATRICS, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/26/2006
Last Update Date: 03/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10410 PARK RD SUITE 100
CHARLOTTE NC
28210-8474
US

IV. Provider business mailing address

1636 LOOKOUT CIR
WAXHAW NC
28173-8085
US

V. Phone/Fax

Practice location:
  • Phone: 704-540-6860
  • Fax:
Mailing address:
  • Phone: 704-540-6860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: NEETA KUKREJA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 704-540-6860