Provider Demographics
NPI:1417566779
Name:OLD TOWN M.D.
Entity Type:Organization
Organization Name:OLD TOWN M.D.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAZZELLA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-709-9362
Mailing Address - Street 1:500 WESTOVER DR STE 10417
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-8941
Mailing Address - Country:US
Mailing Address - Phone:704-709-9362
Mailing Address - Fax:
Practice Address - Street 1:500 WESTOVER DR STE 10417
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-8941
Practice Address - Country:US
Practice Address - Phone:704-709-9362
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-23
Last Update Date:2020-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty