Healthcare Provider Details

I. General information

NPI: 1760483689
Provider Name (Legal Business Name): THOMAS PAUL MUTTON M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2005
Last Update Date: 10/25/2020
Certification Date: 09/06/2020
Deactivation Date: 03/22/2006
Reactivation Date: 03/27/2006

III. Provider practice location address

1900 S HAWTHORNE RD SUITE 480
WINSTON SALEM NC
27103-3913
US

IV. Provider business mailing address

1900 S HAWTHORNE RD SUITE 480
WINSTON SALEM NC
27103-3913
US

V. Phone/Fax

Practice location:
  • Phone: 336-765-0155
  • Fax: 336-765-5494
Mailing address:
  • Phone: 336-765-0155
  • Fax: 336-765-5494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number18688
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number18688
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: