Provider Demographics
NPI:1154983096
Name:ALTIER, JAKE WILLIAM (MD)
Entity type:Individual
Prefix:DR
First Name:JAKE
Middle Name:WILLIAM
Last Name:ALTIER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 751874
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1874
Mailing Address - Country:US
Mailing Address - Phone:843-402-5200
Mailing Address - Fax:
Practice Address - Street 1:2085 HENRY TECKLENBURG DR STE 320
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29414-7713
Practice Address - Country:US
Practice Address - Phone:843-571-6067
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2025-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC82942207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC829429Medicaid