Provider Demographics
NPI:1437130424
Name:MAZZOLA, TIMOTHY JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JOSEPH
Last Name:MAZZOLA
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 21928
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4116
Mailing Address - Country:US
Mailing Address - Phone:720-463-0567
Mailing Address - Fax:303-494-5371
Practice Address - Street 1:5420 ARAPAHOE AVE STE A
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80303-1250
Practice Address - Country:US
Practice Address - Phone:720-463-0567
Practice Address - Fax:303-494-5371
Is Sole Proprietor?:No
Enumeration Date:2005-11-08
Last Update Date:2023-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO41636207QS0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO86956311Medicaid
CO86956311Medicaid
CO809050Medicare PIN