Provider Demographics
NPI:1487662235
Name:MAZZEO, ROCKY WILLIAM (MD)
Entity Type:Individual
Prefix:DR
First Name:ROCKY
Middle Name:WILLIAM
Last Name:MAZZEO
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 1:6007B 244TH ST SW
Mailing Address - Street 2:BALLINGER CLINIC
Mailing Address - City:MOUNTLAKE TERRACE
Mailing Address - State:WA
Mailing Address - Zip Code:98043
Mailing Address - Country:US
Mailing Address - Phone:425-640-4830
Mailing Address - Fax:425-640-4885
Practice Address - Street 1:6007B 244TH ST SW
Practice Address - Street 2:BALLINGER CLINIC
Practice Address - City:MOUNTLAKE TERRACE
Practice Address - State:WA
Practice Address - Zip Code:98043
Practice Address - Country:US
Practice Address - Phone:425-640-4830
Practice Address - Fax:425-640-4885
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00027747207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8127532Medicaid
E98247Medicare UPIN
WAAB21071Medicare ID - Type Unspecified