Provider Demographics
NPI:1033162219
Name:MAZZELLA, MARCO S (MD)
Entity Type:Individual
Prefix:
First Name:MARCO
Middle Name:S
Last Name:MAZZELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 NE RALPH POWELL RD
Mailing Address - Street 2:
Mailing Address - City:LEES SUMMIT
Mailing Address - State:MO
Mailing Address - Zip Code:64064-2301
Mailing Address - Country:US
Mailing Address - Phone:816-525-1600
Mailing Address - Fax:816-525-0173
Practice Address - Street 1:7201 E 147TH ST
Practice Address - Street 2:
Practice Address - City:GRANDVIEW
Practice Address - State:MO
Practice Address - Zip Code:64030-4204
Practice Address - Country:US
Practice Address - Phone:816-416-4900
Practice Address - Fax:816-416-4901
Is Sole Proprietor?:No
Enumeration Date:2006-05-18
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0428890207RC0000X
MO2004017280207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1033162219Medicaid
7563574OtherAETNA
A030OtherAETNA PPO
MOP00853573OtherMEDICARE RAILROAD
34436012OtherAETNA HMO
7563574OtherBLUE SHIELD OF KC PPO
P000149535OtherRAILROAD MEDICARE
431092652OtherTRICARE CHAMPUS
7563574OtherBLUE SHIELD OF KC HMO
MOP01128616OtherRAILROAD MEDICARE
34436012OtherAETNA HMO
I16385Medicare UPIN
MOP01128616OtherRAILROAD MEDICARE
MOMA2231008Medicare PIN
MO1033162219Medicaid