Provider Demographics
NPI:1639175219
Name:COLETTA, HARRY MARIO II (MD)
Entity Type:Individual
Prefix:DR
First Name:HARRY
Middle Name:MARIO
Last Name:COLETTA
Suffix:II
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:PO BOX 678
Mailing Address - Street 2:
Mailing Address - City:WALNUT COVE
Mailing Address - State:NC
Mailing Address - Zip Code:27052-0678
Mailing Address - Country:US
Mailing Address - Phone:336-591-7205
Mailing Address - Fax:336-591-5114
Practice Address - Street 1:106 E 8TH ST
Practice Address - Street 2:
Practice Address - City:WALNUT COVE
Practice Address - State:NC
Practice Address - Zip Code:27052-9399
Practice Address - Country:US
Practice Address - Phone:336-591-7205
Practice Address - Fax:336-591-5114
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC24054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC121OtherPARTNERS MCR CHOICE
NC8923756Medicaid
NC23756OtherBSBS
NC202317Medicare ID - Type Unspecified
NC121OtherPARTNERS MCR CHOICE