=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104169135
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DAVID MAZARIEGOS M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/27/2013
-----------------------------------------------------
Last Update Date | 12/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 155 N FRESNO ST
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93701-2302
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-577-9290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1050 E HERNDON AVE APT 171
-----------------------------------------------------
City | FRESNO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93720-3152
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 832-577-9290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number | A137509
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------