Provider Demographics
NPI:1578508933
Name:MAZZARELLA, JARETT A (OD)
Entity Type:Individual
Prefix:
First Name:JARETT
Middle Name:A
Last Name:MAZZARELLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1601 BRENNER AVE
Mailing Address - Street 2:11-1 (OPTOMETRY SERVICE)
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28144-2515
Mailing Address - Country:US
Mailing Address - Phone:814-241-6519
Mailing Address - Fax:
Practice Address - Street 1:1601 BRENNER AVE
Practice Address - Street 2:11-1 (OPTOMETRY SERVICE)
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28144-2515
Practice Address - Country:US
Practice Address - Phone:814-241-6519
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2002152W00000X
PAOEG001701152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904113Medicaid
NC5904113Medicaid