1326050725 NPI number — DR. JANCY F UTOH MD

Table of content: DR. JANCY F UTOH MD (NPI 1326050725)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326050725 NPI number — DR. JANCY F UTOH MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
UTOH
Provider First Name:
JANCY
Provider Middle Name:
F
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1326050725
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/12/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6801 SOUTH BLVD STE D&E
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28217-4458
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-451-9679
Provider Business Mailing Address Fax Number:
704-643-7295

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
644 CLARK DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LINCOLNTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28092-3714
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
980-212-2680
Provider Business Practice Location Address Fax Number:
980-212-2690
Provider Enumeration Date:
08/13/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  SC28391 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X , with the licence number: 2005-01936 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 283912 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5902894 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".