Provider Demographics
NPI:1932288123
Name:MAZZARELLA, LESLIE ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LESLIE
Middle Name:ANN
Last Name:MAZZARELLA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:328 N FAYETTEVILLE ST STE A
Mailing Address - Street 2:
Mailing Address - City:ASHEBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27203-5594
Mailing Address - Country:US
Mailing Address - Phone:336-625-2020
Mailing Address - Fax:
Practice Address - Street 1:328 N FAYETTEVILLE ST STE A
Practice Address - Street 2:
Practice Address - City:ASHEBORO
Practice Address - State:NC
Practice Address - Zip Code:27203-5594
Practice Address - Country:US
Practice Address - Phone:336-625-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-06
Last Update Date:2022-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001794152WC0802X
NC2035152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1022153830001Medicaid
NC5907116Medicaid
NC5907116Medicaid