Healthcare Provider Details

I. General information

NPI: 1396843132
Provider Name (Legal Business Name): KHALED F JREISAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 08/29/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3806 PEACHTREE AVE SUITE 110
WILMINGTON NC
28403-6751
US

IV. Provider business mailing address

34 OFFICE PARK DR STE 100
JACKSONVILLE NC
28546-3221
US

V. Phone/Fax

Practice location:
  • Phone: 910-399-4197
  • Fax: 910-399-4223
Mailing address:
  • Phone: 910-353-3624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number11599
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number27377
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: