Healthcare Provider Details

I. General information

NPI: 1760447890
Provider Name (Legal Business Name): RICHARD MAZO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/20/2006
Last Update Date: 01/04/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

230 E DERENNE AVE
SAVANNAH GA
31405-6736
US

IV. Provider business mailing address

5002 WATERS AVE
SAVANNAH GA
31404-6226
US

V. Phone/Fax

Practice location:
  • Phone: 912-790-4000
  • Fax: 912-790-4407
Mailing address:
  • Phone: 912-350-7914
  • Fax: 912-350-7973

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number028045
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code2088P0231X
TaxonomyPediatric Urology Physician
License Number028045
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: