Healthcare Provider Details

I. General information

NPI: 1619061124
Provider Name (Legal Business Name): MARK WILLIAM YEAZEL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 WEST BROADWAY
MINNEAPOLIS MN
55411
US

IV. Provider business mailing address

720 WASHIGNTON AVE SE UNIVERSITY OF MINNESOTA PHYSICIANS
MINNEAPOLIS MN
55414
US

V. Phone/Fax

Practice location:
  • Phone: 612-302-8200
  • Fax: 612-302-8275
Mailing address:
  • Phone: 612-884-0649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31743
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: