Healthcare Provider Details

I. General information

NPI: 1891769709
Provider Name (Legal Business Name): MARK A MAZZARE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 10/24/2023
Certification Date: 10/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5380 OLD BULLARD RD STE 600-357
TYLER TX
75703-3607
US

IV. Provider business mailing address

5380 OLD BULLARD RD STE 600-357
TYLER TX
75703-3607
US

V. Phone/Fax

Practice location:
  • Phone: 888-316-5498
  • Fax: 888-979-6378
Mailing address:
  • Phone: 888-316-5498
  • Fax: 888-979-6378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberK3331
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: