Provider Demographics
NPI:1457368185
Name:MAZZOLA, JOSEPH C (DO)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:C
Last Name:MAZZOLA
Suffix:
Gender:M
Credentials:DO
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 896199
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-6199
Mailing Address - Country:US
Mailing Address - Phone:833-936-1364
Mailing Address - Fax:605-942-7505
Practice Address - Street 1:310 DAVIE AVE
Practice Address - Street 2:
Practice Address - City:STATESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28677-5319
Practice Address - Country:US
Practice Address - Phone:704-873-3269
Practice Address - Fax:704-871-8159
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049190207Q00000X
NC2010-01894207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5916859Medicaid
GA00911787EMedicaid
NCNC2409A293OtherMEDICARE PTAN
NCNC2409A293OtherMEDICARE PTAN