Basic Information
| Provider Information | |||||||||
| NPI: | 1811914435 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | AZZATO | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11515 | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284611515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9104548030 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1513 N HOWE ST STE 4 | ||||||||
| Address2: | |||||||||
| City: | SOUTHPORT | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284612770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9108055578 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/17/2006 | ||||||||
| LastUpdateDate: | 08/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 202C00000X | 20698 | NC | N | Allopathic & Osteopathic Physicians | Independent Medical Examiner | 208D00000X | 20698 | NC | N | Allopathic & Osteopathic Physicians | General Practice | 2251X0800X | 20698 | NC | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | Orthopedic | 207X00000X | 20698 | NC | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 8912440 | 05 | NC | MEDICAID |