Provider Demographics
NPI:1760447890
Name:MAZO, RICHARD (MD)
Entity Type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:
Last Name:MAZO
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 1:5002 WATERS AVE
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:GA
Mailing Address - Zip Code:31404-6226
Mailing Address - Country:US
Mailing Address - Phone:912-350-7914
Mailing Address - Fax:912-350-7973
Practice Address - Street 1:230 E DERENNE AVE
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31405-6736
Practice Address - Country:US
Practice Address - Phone:912-790-4000
Practice Address - Fax:912-790-4407
Is Sole Proprietor?:No
Enumeration Date:2006-04-20
Last Update Date:2022-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA028045208800000X, 2088P0231X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2088P0231XAllopathic & Osteopathic PhysiciansUrologyPediatric Urology
No208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000324365FMedicaid
GA000324365FMedicaid
GAD40579Medicare UPIN