Provider Demographics
NPI:1336215078
Name:MEZONA ORTHOPAEDIC PA
Entity Type:Organization
Organization Name:MEZONA ORTHOPAEDIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:PROCKNOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-964-2908
Mailing Address - Street 1:500 W 10TH PL
Mailing Address - Street 2:STE 121
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85201-3216
Mailing Address - Country:US
Mailing Address - Phone:480-964-2908
Mailing Address - Fax:480-833-2136
Practice Address - Street 1:6550 E BROADWAY RD
Practice Address - Street 2:STE 108
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-1732
Practice Address - Country:US
Practice Address - Phone:480-964-2908
Practice Address - Fax:480-833-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ20WCHFCMedicare ID - Type UnspecifiedGROUP NUMBER