Provider Demographics
NPI:1497736961
Name:SCOVAZZO, MARY LYNN (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LYNN
Last Name:SCOVAZZO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:875 SWIFT BLVD
Mailing Address - Street 2:
Mailing Address - City:RICHLAND
Mailing Address - State:WA
Mailing Address - Zip Code:99352-3592
Mailing Address - Country:US
Mailing Address - Phone:509-946-1654
Mailing Address - Fax:
Practice Address - Street 1:875 SWIFT BLVD
Practice Address - Street 2:
Practice Address - City:RICHLAND
Practice Address - State:WA
Practice Address - Zip Code:99352-3592
Practice Address - Country:US
Practice Address - Phone:509-946-1654
Practice Address - Fax:509-943-5652
Is Sole Proprietor?:No
Enumeration Date:2005-11-10
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00041636207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8331241Medicaid
WA162809OtherSTATE INDUSTRIAL
WA1497736961Medicaid
WA1497736961Medicaid
E64218Medicare UPIN