Healthcare Provider Details

I. General information

NPI: 1215513742
Provider Name (Legal Business Name): JACOB ALAN DAUTEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD STE 601
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

2630 E 7TH ST STE 100
CHARLOTTE NC
28204-4319
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-7874
  • Fax: 704-355-5619
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2026-00863
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: