Provider Demographics
NPI:1588872642
Name:CLAYTOR, TEDRA MICHELLE (MD)
Entity type:Individual
Prefix:
First Name:TEDRA
Middle Name:MICHELLE
Last Name:CLAYTOR
Suffix:
Gender:F
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 MEDICAL PARK DR
Practice Address - Street 2:STE 280
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-2982
Practice Address - Country:US
Practice Address - Phone:704-403-1766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-20
Last Update Date:2024-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01076207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC149RVOtherBCBSNC
NC5909741Medicaid
NC1588872642Medicaid
NC2008-01076OtherLICENSE
NCP00963703OtherRAILROAD GROUP - 0322
NC1588872642Medicaid
NCP00963703OtherRAILROAD GROUP - 0322
NCNCG745C904Medicare PIN