Healthcare Provider Details

I. General information

NPI: 1699188912
Provider Name (Legal Business Name): MICHAEL LEON TJAHJADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/04/2014
Last Update Date: 07/28/2025
Certification Date: 07/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

728 HARTNESS RD
STATESVILLE NC
28677-3425
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-6420
  • Fax:
Mailing address:
  • Phone: 704-874-1904
  • Fax: 704-865-4614

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2023-02709
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: