Provider Demographics
NPI:1841427572
Name:MAZZOTTA, MICHAEL (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:
Last Name:MAZZOTTA
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 1:4212 NE BROADWAY
Mailing Address - Street 2:MEDICAL STAFF SVCS
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97213-1422
Mailing Address - Country:US
Mailing Address - Phone:503-382-7709
Mailing Address - Fax:503-382-7706
Practice Address - Street 1:4212 NE BROADWAY
Practice Address - Street 2:MEDICAL STAFF SVCS
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97213-1422
Practice Address - Country:US
Practice Address - Phone:503-382-7709
Practice Address - Fax:503-382-7706
Is Sole Proprietor?:No
Enumeration Date:2009-06-21
Last Update Date:2022-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR173217207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine