Healthcare Provider Details

I. General information

NPI: 1154061216
Provider Name (Legal Business Name): JEDIDIAH AARON MAHAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/02/2026
Certification Date: 03/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 CROOKED CREEK PKWY
DURHAM NC
27713-8505
US

IV. Provider business mailing address

2301 ERWIN RD
DURHAM NC
27705-4699
US

V. Phone/Fax

Practice location:
  • Phone: 919-620-5333
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number310546
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: