Provider Demographics
NPI:1720219470
Name:MAZZARE, ANDREA NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:ANDREA
Middle Name:NICOLE
Last Name:MAZZARE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:ANDREA
Other - Middle Name:NICOLE
Other - Last Name:NEWTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1104 EASY ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-7128
Mailing Address - Country:US
Mailing Address - Phone:918-320-8909
Mailing Address - Fax:
Practice Address - Street 1:211 N 5TH ST
Practice Address - Street 2:
Practice Address - City:MCALESTER
Practice Address - State:OK
Practice Address - Zip Code:74501-4713
Practice Address - Country:US
Practice Address - Phone:918-426-0106
Practice Address - Fax:918-426-0443
Is Sole Proprietor?:No
Enumeration Date:2009-07-29
Last Update Date:2018-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist