Healthcare Provider Details

I. General information

NPI: 1790239101
Provider Name (Legal Business Name): JACK XU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2016
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

IV. Provider business mailing address

155 MEMORIAL DR
PINEHURST NC
28374-8710
US

V. Phone/Fax

Practice location:
  • Phone: 910-715-7650
  • Fax: 910-715-7928
Mailing address:
  • Phone: 910-715-1650
  • Fax: 910-235-7928

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2022-01767
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE-12710
License Number StateAR
# 3
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number2022-01767
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: