Healthcare Provider Details

I. General information

NPI: 1134573439
Provider Name (Legal Business Name): JOHN A AZZATO MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2016
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1503 E BROAD ST
STATESVILLE NC
28625-4301
US

IV. Provider business mailing address

PO BOX 11505
SOUTHPORT NC
28461-1505
US

V. Phone/Fax

Practice location:
  • Phone: 704-871-9731
  • Fax: 704-871-1105
Mailing address:
  • Phone: 910-454-8030
  • Fax: 910-363-4828

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JOHN A AZZATO
Title or Position: OWNER
Credential: MD
Phone: 910-454-8030