Healthcare Provider Details

I. General information

NPI: 1497795553
Provider Name (Legal Business Name): JOHN JOSEPH MEZZULLO DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 09/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 VILLAGE WAY
TRENT WOODS NC
28562-7305
US

IV. Provider business mailing address

2800 VILLAGE WAY
TRENT WOODS NC
28562-7305
US

V. Phone/Fax

Practice location:
  • Phone: 252-637-7300
  • Fax: 252-637-1772
Mailing address:
  • Phone: 252-637-7300
  • Fax: 252-637-1772

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number9900611
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number9900611
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: