Healthcare Provider Details

I. General information

NPI: 1538517164
Provider Name (Legal Business Name): JUSTIN MARK CAPPUZZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2016
Last Update Date: 02/09/2024
Certification Date: 02/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2800 ASHTON DR
WILMINGTON NC
28412-2575
US

IV. Provider business mailing address

2800 ASHTON DR
WILMINGTON NC
28412-2575
US

V. Phone/Fax

Practice location:
  • Phone: 910-799-2262
  • Fax: 910-799-2943
Mailing address:
  • Phone: 910-799-2262
  • Fax: 910-799-2943

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number314140
License Number StateNY
# 3
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number2022-03260
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number267005
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: