=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205815685
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OAK ISLAND PEDIATRICS, P.A.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/12/2006
-----------------------------------------------------
Last Update Date | 11/20/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4734 LONG BEACH RD SE
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-457-0070
-----------------------------------------------------
Fax | 910-457-0062
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4734 LONG BEACH RD SE
-----------------------------------------------------
City | SOUTHPORT
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28461-8721
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-457-0070
-----------------------------------------------------
Fax | 910-457-0062
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JUGTA KAHAI
-----------------------------------------------------
Credential | M.D., F.A.A.P.
-----------------------------------------------------
Telephone | 910-457-0070
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 101Y00000X
-----------------------------------------------------
Taxonomy Name | Counselor
-----------------------------------------------------
License Number | 4773
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 103T00000X
-----------------------------------------------------
Taxonomy Name | Psychologist
-----------------------------------------------------
License Number | 3068
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 9900076
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------