=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437130424
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | TIMOTHY JOSEPH MAZZOLA M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/08/2005
-----------------------------------------------------
Last Update Date | 09/24/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5420 ARAPAHOE AVE STE A
-----------------------------------------------------
City | BOULDER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80303-1250
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-463-0567
-----------------------------------------------------
Fax | 303-494-5371
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 21928
-----------------------------------------------------
City | BELFAST
-----------------------------------------------------
State | ME
-----------------------------------------------------
Zip | 04915-4116
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 720-463-0567
-----------------------------------------------------
Fax | 303-494-5371
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207QS0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Family Medicine) Physician
-----------------------------------------------------
License Number | 41636
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------