Provider Demographics
NPI:1053518555
Name:JETER, ASHLEY ABIDE (MD)
Entity type:Individual
Prefix:DR
First Name:ASHLEY
Middle Name:ABIDE
Last Name:JETER
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 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 1:2910 TRICOM ST
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-9350
Practice Address - Country:US
Practice Address - Phone:843-572-9211
Practice Address - Fax:843-572-0458
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2022-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC30018207RH0003X
TXP7932207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC300187Medicaid
TX334794002Medicaid
TX334794002Medicaid
TX330185YK4EMedicare PIN