Provider Demographics
NPI:1366474041
Name:MAZZOLA, MARION BETH (MD)
Entity Type:Individual
Prefix:
First Name:MARION
Middle Name:BETH
Last Name:MAZZOLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:BETH
Other - Middle Name:
Other - Last Name:MAZZOLA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1735 S PUBLIC RD STE 203
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:CO
Mailing Address - Zip Code:80026-7093
Mailing Address - Country:US
Mailing Address - Phone:303-665-3036
Mailing Address - Fax:303-665-3397
Practice Address - Street 1:2525 13TH ST
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80304-4104
Practice Address - Country:US
Practice Address - Phone:303-449-6050
Practice Address - Fax:720-565-4132
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0042162207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO58200363Medicaid
CO58200363Medicaid