Provider Demographics
NPI:1336129535
Name:PETRUZZIELLO, MARK (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:
Last Name:PETRUZZIELLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CLINIC DR
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-1935
Mailing Address - Country:US
Mailing Address - Phone:252-823-2105
Mailing Address - Fax:
Practice Address - Street 1:101 CLINIC DR
Practice Address - Street 2:
Practice Address - City:TARBORO
Practice Address - State:NC
Practice Address - Zip Code:27886-1935
Practice Address - Country:US
Practice Address - Phone:252-823-2105
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200001243208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1756614OtherUNITED HEALTHCARE
NCA1917OtherMEDCOST
NC020047543OtherRAILROAD MEDICARE
NC89127R6Medicaid
NC127R6OtherBCBS
NC2281259Medicare ID - Type Unspecified
NC89127R6Medicaid