Provider Demographics
NPI:1790045409
Name:JOHN A AZZATO MD PC
Entity Type:Organization
Organization Name:JOHN A AZZATO MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:
Authorized Official - Last Name:PHILLIPS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-805-5578
Mailing Address - Street 1:PO BOX 11505
Mailing Address - Street 2:
Mailing Address - City:SOUTHPORT
Mailing Address - State:NC
Mailing Address - Zip Code:28461-1505
Mailing Address - Country:US
Mailing Address - Phone:910-805-5578
Mailing Address - Fax:
Practice Address - Street 1:1513 N HOWE ST
Practice Address - Street 2:SUITE 4
Practice Address - City:SOUTHPORT
Practice Address - State:NC
Practice Address - Zip Code:28461-2769
Practice Address - Country:US
Practice Address - Phone:910-805-5578
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-29
Last Update Date:2013-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC20698202C00000X, 207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Multi-Specialty
No202C00000XAllopathic & Osteopathic PhysiciansIndependent Medical ExaminerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8912440Medicaid
NCC81520Medicare UPIN
NC202845Medicare PIN