MEDICARE: DR. MARK LAWRENCE MAZOW M.D.

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	207WX0200X	Ophthalmic Plastic and Reconstructive Surgery Physician	H2575	TX
2	207W00000X	Ophthalmology Physician	H2575	TX

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
11	8658B7	OTHER	TX	MEDICARE DEFAULT
15	180009584	OTHER	TX	RAILROAD MEDICARE

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	131458501	OTHER	TX	CID
3	388561	OTHER	TX	WELLCARE PPO
4	4232994	OTHER	TX	AETNA PPO, POS, & EPO
5	081148	OTHER	TX	PCA
6	20801	OTHER	TX	TOTAL VISION HEALTHCARE
7	29761	OTHER	TX	AMERIGROUP/AMERICAID
8	2819152007	OTHER	TX	TOTAL VISION HEALTHCARE
9	5692	OTHER	TX	PARKLAND KIDS FIRST
10	3566323	OTHER	TX	HEALTH MARKET
12	H2575	OTHER	TX	UNICARE
13	0612278	OTHER	TX	AETNA HMO
14	8658B7	OTHER	TX	BCBS
16	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
17	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
18	358046	OTHER	TX	ONE HEALTH
19	388561	OTHER	TX	WELLCARE HMO

General Provider Information

NPI Number	:	1639173669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARK LAWRENCE MAZOW M.D.

Provider Business Mailing Address
First Line	:	7777 FOREST LANE
Second Line	:	SUITE C-710
City	:	DALLAS
State	:	TX
Zip	:	75230-2571
Country	:	US
Telephone Number	:	972-566-2020
Fax Number	:	972-566-5454

Provider Business Practice Location Address
First Line	:	7777 FOREST LANE
Second Line	:	SUITE C-710
City	:	DALLAS
State	:	TX
Zip	:	75230-2571
Country	:	US
Telephone Number	:	972-566-2020
Fax Number	:	972-566-5454

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

Provider Enumeration Date	:	06/08/2005
Last Update Date	:	11/02/2022

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