Healthcare Provider Details

I. General information

NPI: 1417536459
Provider Name (Legal Business Name): MICHAEL THOMAS MASTROPOLE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/06/2021
Last Update Date: 12/30/2024
Certification Date: 12/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4205 BEN FRANKLIN BLVD
DURHAM NC
27704-2143
US

IV. Provider business mailing address

13 CAROLINA ST APT B
CHARLESTON SC
29403-4789
US

V. Phone/Fax

Practice location:
  • Phone: 919-477-6900
  • Fax: 919-620-0974
Mailing address:
  • Phone: 704-300-8368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2024-02536
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: