MEDICARE: DR. MARK RICHARD GAZALL D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208600000X	Surgery Physician	34-005012	OH

General Provider Information

NPI Number	:	1124068622
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK RICHARD GAZALL D.O.

Provider Business Mailing Address
First Line	:	2141 N. FAIRFIELD RD
Second Line	:	SUITE B.
City	:	BREAVER CREEK
State	:	OH
Zip	:	45431-2579
Country	:	US
Telephone Number	:	937-458-0085
Fax Number	:	937-458-0212

Provider Business Practice Location Address
First Line	:	6503 E BROAD ST STE 200
Second Line	:
City	:	COLUMBUS
State	:	OH
Zip	:	43213-1693
Country	:	US
Telephone Number	:	614-810-1300
Fax Number	:	614-614-1301

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/07/2006
Last Update Date	:	07/11/2022

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