Healthcare Provider Details

I. General information

NPI: 1407805823
Provider Name (Legal Business Name): BRIAN DEREK BUZZEO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 05/26/2021
Certification Date: 05/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 COX RD
GASTONIA NC
28054-3438
US

IV. Provider business mailing address

9735 KINCEY AVE STE 201
HUNTERSVILLE NC
28078-9118
US

V. Phone/Fax

Practice location:
  • Phone: 704-864-7764
  • Fax: 704-867-7894
Mailing address:
  • Phone: 704-414-2870
  • Fax: 704-414-2860

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number9700207
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: