Healthcare Provider Details

I. General information

NPI: 1174561872
Provider Name (Legal Business Name): MARK R. GAZALL, D.O., LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 08/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 N. FAIRFIELD RD, SUITE B.
BREAVER CREEK OH
45431-2579
US

IV. Provider business mailing address

2141 N. FAIRFIELD RD, SUITE B.
BREAVER CREEK OH
45431-2579
US

V. Phone/Fax

Practice location:
  • Phone: 937-458-0085
  • Fax: 937-458-0212
Mailing address:
  • Phone: 937-458-0085
  • Fax: 937-458-0212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number34-005012
License Number StateOH

VIII. Authorized Official

Name: SCOTT E STEINER
Title or Position: ASSISTANT.
Credential: RT(R)(ARRT)
Phone: 937-458-0085