Provider Demographics
NPI:1548253347
Name:GAZZUOLO, DEBRA J (MD)
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:J
Last Name:GAZZUOLO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DEBORAH
Other - Middle Name:J
Other - Last Name:GAZZUOLO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:6115 PARK SOUTH DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28210-3281
Mailing Address - Country:US
Mailing Address - Phone:704-554-8787
Mailing Address - Fax:704-554-8774
Practice Address - Street 1:6115 PARK SOUTH DR STE 100
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-3281
Practice Address - Country:US
Practice Address - Phone:704-554-8787
Practice Address - Fax:704-554-8774
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2017-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCSC23339207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC233394Medicaid
SCG34051Medicare UPIN