Provider Demographics
NPI:1720079726
Name:MAZYCK, EARLE F (MD)
Entity Type:Individual
Prefix:DR
First Name:EARLE
Middle Name:F
Last Name:MAZYCK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1118 ROSS CLARK CIR
Mailing Address - Street 2:SUITE 303
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-3001
Mailing Address - Country:US
Mailing Address - Phone:334-794-3192
Mailing Address - Fax:334-792-7513
Practice Address - Street 1:1118 ROSS CLARK CIR
Practice Address - Street 2:SUITE 303
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-3001
Practice Address - Country:US
Practice Address - Phone:334-794-3192
Practice Address - Fax:334-792-7513
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-31
Last Update Date:2009-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL6961207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL051552726Medicaid
AL051512613OtherAL BLUE CROSS PROVIDER
ALP00009152OtherRRMC PROVIDER NUMBER
FL61659OtherFLORIDA BLUE CROSS NUMBER
AL4790691001OtherCIGNA PROVIDER NUMBER
GA00063192AOtherGEORGIA MEDICAID NUMBER
ALP00009152OtherRRMC PROVIDER NUMBER
AL051552726Medicaid