Healthcare Provider Details

I. General information

NPI: 1790045409
Provider Name (Legal Business Name): JOHN A AZZATO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/29/2012
Last Update Date: 01/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1513 N HOWE ST SUITE 4
SOUTHPORT NC
28461-2769
US

IV. Provider business mailing address

PO BOX 11505
SOUTHPORT NC
28461-1505
US

V. Phone/Fax

Practice location:
  • Phone: 910-805-5578
  • Fax:
Mailing address:
  • Phone: 910-805-5578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code202C00000X
TaxonomyIndependent Medical Examiner Physician
License Number20698
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number20698
License Number StateNC

VIII. Authorized Official

Name: JEAN PHILLIPS
Title or Position: OFFICE MANAGER
Credential:
Phone: 910-805-5578