Provider Demographics
NPI:1033317862
Name:MAZZOLA, DAVID JOHN
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:JOHN
Last Name:MAZZOLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3151 E HOLLADAY ST
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85706-2819
Mailing Address - Country:US
Mailing Address - Phone:520-889-2453
Mailing Address - Fax:
Practice Address - Street 1:3151 E HOLLADAY ST
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85706-2819
Practice Address - Country:US
Practice Address - Phone:520-889-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-03
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9209385HR2055X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ894429Medicaid