Individual
JAY ANTHONY REQUARTH
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
MEDICAL CENTER BLVD, WINSTON SALEM, NC 27157-0001
(336) 716-2255
Mailing address
PO BOX 344, WINSTON-SALEM, NC 27102-0344
(336) 716-2255
Taxonomy
Speciality
Code
Description
License number
State
2085R0204X
Vascular & Interventional Radiology Physician
Primary
2005-00403
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
10411491
—
VA
01
—
142J0
BCBS
—
01
—
189351
MEDCOST
—
01
—
4556618
AETNA
—
05
—
5904790
—
NC
01
—
808939
PARTNERS
—
05
—
86138000
—
WV
Enumeration date
06/30/2006
Last updated
01/27/2012
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