=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700449295
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JERRY PATRICK SKUTHAN DO
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/19/2019
-----------------------------------------------------
Last Update Date | 10/02/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4414 LAKE BOONE TRL STE 402
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-7520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-567-6133
-----------------------------------------------------
Fax | 919-567-6134
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4414 LAKE BOONE TRL STE 402
-----------------------------------------------------
City | RALEIGH
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27607-7520
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 919-567-6133
-----------------------------------------------------
Fax | 919-567-6134
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number | 2025-02910
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------