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General NPI Number Information
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NPI Number | 1417976234
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Entity Type | Individual
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Provider Name | JACK D ANDERSON
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Gender | Male
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Dates
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Enumeration Date | 07/19/2006
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Last Update Date | 06/25/2013
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Provider Practice Location Address
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Address Line | 7030 PINEVILLE MATTHEWS RD
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City | CHARLOTTE
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State | NC
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Zip | 28226-8298
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Country | US
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Telephone | 704-667-4150
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Fax | 704-752-7040
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Provider Business Mailing Address
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Address Line | PO BOX 601067
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City | CHARLOTTE
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State | NC
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Zip | 28260-1067
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Country | US
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Telephone | 704-667-4150
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Fax | 704-752-7040
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 30586
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License Number State | NC
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