Healthcare Provider Details

I. General information

NPI: 1083877997
Provider Name (Legal Business Name): MTM&M PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2008
Last Update Date: 05/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4111 WENDELL BLVD
WENDELL NC
27591-6831
US

IV. Provider business mailing address

4111 WENDELL BLVD
WENDELL NC
27591-6831
US

V. Phone/Fax

Practice location:
  • Phone: 919-365-8484
  • Fax: 919-365-8450
Mailing address:
  • Phone: 919-365-8484
  • Fax: 919-365-8450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number30615
License Number StateNC

VIII. Authorized Official

Name: DR. ROBERT E CLAYTON
Title or Position: PRESIDENT
Credential: M.D.
Phone: 919-261-9727