Provider Demographics
NPI:1619061124
Name:YEAZEL, MARK WILLIAM (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:WILLIAM
Last Name:YEAZEL
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:720 WASHIGNTON AVE SE
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55414
Mailing Address - Country:US
Mailing Address - Phone:612-884-0649
Mailing Address - Fax:
Practice Address - Street 1:1020 WEST BROADWAY
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55411
Practice Address - Country:US
Practice Address - Phone:612-302-8200
Practice Address - Fax:612-302-8275
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2012-04-23
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MN31743207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN092585OtherFAIRVIEW
MN570002700Medicaid
MN01-03328OtherMEDICA - CHOICE
MN100588OtherUCARE
MN58D72YEOtherBLUE CROSS BLUE SHIELD
MNHP17443OtherHEALTHPARTNERS
MN1009362OtherPREFERREDONE
MN768420OtherARAZ
MN01-03328OtherMEDICA - CHOICE