Provider Demographics
NPI:1811346554
Name:MAZZARE VISION GROUP, PLLC
Entity type:Organization
Organization Name:MAZZARE VISION GROUP, PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MAZZARE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:918-426-0106
Mailing Address - Street 1:211 N 5TH ST
Mailing Address - Street 2:
Mailing Address - City:MCALESTER
Mailing Address - State:OK
Mailing Address - Zip Code:74501-4713
Mailing Address - Country:US
Mailing Address - Phone:918-426-0106
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:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-03
Last Update Date:2019-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK2618152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty