Basic Information
Provider Information
NPI: 1003295072
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MANY
FirstName: JEFFREY
MiddleName: RICHARD
NamePrefix:  
NameSuffix:  
Credential: M.D.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 60447
Address2:  
City: CHARLOTTE
State: NC
PostalCode: 282600447
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 269 GILLMAN RD
Address2: STE 100
City: DENVER
State: NC
PostalCode: 280373007
CountryCode: US
TelephoneNumber: 7043164930
FaxNumber: 7043164931
Other Information
ProviderEnumerationDate: 05/23/2015
LastUpdateDate: 10/26/2020
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate: 09/06/2020

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207Q00000X2018-00652NCY Allopathic & Osteopathic PhysiciansFamily Medicine 
207Q00000X38055SCN Allopathic & Osteopathic PhysiciansFamily Medicine 

No ID Information.


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