MEDICARE: DR. HARRY MARIO COLETTA II MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	24054	NC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	121	OTHER	NC	PARTNERS MCR CHOICE
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	23756	OTHER	NC	BSBS

General Provider Information

NPI Number	:	1639175219
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. HARRY MARIO COLETTA II MD

Provider Business Mailing Address
First Line	:	PO BOX 678
Second Line	:
City	:	WALNUT COVE
State	:	NC
Zip	:	27052-0678
Country	:	US
Telephone Number	:	336-591-7205
Fax Number	:	336-591-5114

Provider Business Practice Location Address
First Line	:	106 E 8TH ST
Second Line	:
City	:	WALNUT COVE
State	:	NC
Zip	:	27052-9399
Country	:	US
Telephone Number	:	336-591-7205
Fax Number	:	336-591-5114

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/28/2005
Last Update Date	:	07/08/2007

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