Healthcare Provider Details

I. General information

NPI: 1568445211
Provider Name (Legal Business Name): MARK MITCHELL GARSKOF M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 03/17/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2963 W WHITE MOUNTAIN BLVD
LAKESIDE AZ
85929-6257
US

IV. Provider business mailing address

2963 W WHITE MOUNTAIN BLVD
LAKESIDE AZ
85929-6257
US

V. Phone/Fax

Practice location:
  • Phone: 928-368-0765
  • Fax: 928-368-4540
Mailing address:
  • Phone: 928-368-0765
  • Fax: 928-368-4540

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number10885
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: