Provider Demographics
NPI:1508808676
Name:CORAZZA, MARK
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:CORAZZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2431 CASTILLO ST
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93105-4301
Mailing Address - Country:US
Mailing Address - Phone:805-569-7115
Mailing Address - Fax:805-563-9091
Practice Address - Street 1:2431 CASTILLO ST
Practice Address - Street 2:
Practice Address - City:SANTA BARBARA
Practice Address - State:CA
Practice Address - Zip Code:93105-4301
Practice Address - Country:US
Practice Address - Phone:805-569-7115
Practice Address - Fax:805-563-9091
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG049062174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC46621Medicare UPIN
CAG49062Medicare ID - Type Unspecified