Provider Demographics
NPI:1568504918
Name:MAZZA, GERARD K (MD)
Entity Type:Individual
Prefix:MR
First Name:GERARD
Middle Name:K
Last Name:MAZZA
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 1:2725 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312
Mailing Address - Country:US
Mailing Address - Phone:423-476-3330
Mailing Address - Fax:423-476-5802
Practice Address - Street 1:2725 KEITH ST NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312
Practice Address - Country:US
Practice Address - Phone:423-476-3330
Practice Address - Fax:423-476-5802
Is Sole Proprietor?:No
Enumeration Date:2007-02-13
Last Update Date:2010-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD015727207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4009361OtherBCBS
TN3841466Medicaid
A97400Medicare UPIN
TN3841462Medicare ID - Type Unspecified