Healthcare Provider Details

I. General information

NPI: 1417513474
Provider Name (Legal Business Name): MARK RAINALDO PORVAZNIK DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2019
Last Update Date: 12/03/2024
Certification Date: 12/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1425 S GREENFIELD RD STE 101
MESA AZ
85206-5505
US

IV. Provider business mailing address

1425 S GREENFIELD RD STE 101
MESA AZ
85206-5505
US

V. Phone/Fax

Practice location:
  • Phone: 809-645-8004
  • Fax:
Mailing address:
  • Phone: 809-645-8004
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number010690
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: