Healthcare Provider Details

I. General information

NPI: 1437130424
Provider Name (Legal Business Name): TIMOTHY JOSEPH MAZZOLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/08/2005
Last Update Date: 09/24/2023
Certification Date: 09/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5420 ARAPAHOE AVE STE A
BOULDER CO
80303-1250
US

IV. Provider business mailing address

PO BOX 21928
BELFAST ME
04915-4116
US

V. Phone/Fax

Practice location:
  • Phone: 720-463-0567
  • Fax: 303-494-5371
Mailing address:
  • Phone: 720-463-0567
  • Fax: 303-494-5371

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License Number41636
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: