Provider Demographics
NPI:1386627115
Name:MEMOLO, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:MEMOLO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:620 SUMMIT CROSSING PL
Mailing Address - Street 2:STE 106
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28054
Mailing Address - Country:US
Mailing Address - Phone:704-867-8021
Mailing Address - Fax:704-864-4606
Practice Address - Street 1:620 SUMMIT CROSSING PL
Practice Address - Street 2:STE 106
Practice Address - City:GASTONIA
Practice Address - State:NC
Practice Address - Zip Code:28054
Practice Address - Country:US
Practice Address - Phone:704-867-8021
Practice Address - Fax:704-864-4606
Is Sole Proprietor?:No
Enumeration Date:2005-11-25
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC332742085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
58609OtherBLUE CROSS BLUE SHIELD
SCN33274Medicaid
12402OtherPARTNERS
73411OtherMEDCOST
NC8958609Medicaid
2353109OtherAETNA HMO
4630736OtherAETNA PPO
300061402OtherRAILROAD MEDICARE
1642996OtherUNITED HEALTHCARE
4630736OtherAETNA PPO
2353109OtherAETNA HMO