Provider Demographics
NPI:1114901394
Name:ZAETTA, MARK A (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:A
Last Name:ZAETTA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 35380
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89133-5380
Mailing Address - Country:US
Mailing Address - Phone:520-290-0300
Mailing Address - Fax:520-298-9230
Practice Address - Street 1:4730 E GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85712-2703
Practice Address - Country:US
Practice Address - Phone:520-290-0300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2022-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25691207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
10093OtherPACFICARE SECURE HORIZONS
110159569OtherRR MEDICARE
860780125OtherCIGNA
1763237OtherUNITED HEALTH CARE
1Z7531OtherHEALTH NET
AZ0811130OtherBLUE CROSS BLUE SHIELD
110159569OtherRR MEDICARE
AZ0811130OtherBLUE CROSS BLUE SHIELD