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General NPI Number Information
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NPI Number | 1699188912
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Entity Type | Individual
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Provider Name | MICHAEL LEON TJAHJADI MD
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Gender | Male
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Dates
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Enumeration Date | 06/04/2014
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Last Update Date | 07/28/2025
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Provider Practice Location Address
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Address Line | 728 HARTNESS RD
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City | STATESVILLE
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State | NC
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Zip | 28677-3425
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Country | US
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Telephone | 704-360-6420
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Fax |
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Provider Business Mailing Address
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Address Line | 200 E 2ND AVE
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City | GASTONIA
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State | NC
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Zip | 28052-4358
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Country | US
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Telephone | 704-874-1904
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Fax | 704-865-4614
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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 | 2023-02709
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License Number State | NC
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