Basic Information
| Provider Information | |||||||||
| NPI: | 1205815685 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | OAK ISLAND PEDIATRICS, P.A. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4734 LONG BEACH RD SE | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284618721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104570070 | ||||||||
| FaxNumber: | 9104570062 | ||||||||
| Practice Location | |||||||||
| Address1: | 4734 LONG BEACH RD SE | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284618721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104570070 | ||||||||
| FaxNumber: | 9104570062 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/12/2006 | ||||||||
| LastUpdateDate: | 11/20/2012 | ||||||||
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| AuthorizedOfficialLastName: | KAHAI | ||||||||
| AuthorizedOfficialFirstName: | JUGTA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9104570070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | M.D., F.A.A.P. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101Y00000X | 4773 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | 103T00000X | 3068 | NC | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Psychologist | 208000000X | 9900076 | NC | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 017HM | 01 | NC | BCBSNC | OTHER | PENDING | 05 | NC | MEDICAID |