Provider Demographics
NPI:1194777219
Name:MAZZULLA, DONALD S (OD)
Entity type:Individual
Prefix:DR
First Name:DONALD
Middle Name:S
Last Name:MAZZULLA
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8724 AZURE SKY DR
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89129-2223
Mailing Address - Country:US
Mailing Address - Phone:702-631-2015
Mailing Address - Fax:702-631-2511
Practice Address - Street 1:4116 W CRAIG RD
Practice Address - Street 2:#104
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032
Practice Address - Country:US
Practice Address - Phone:702-631-2015
Practice Address - Fax:702-631-2511
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2011-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0231152W00000X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV1194777219OtherINDIVIDUAL NPI
NVOD231Medicaid
NVDX280ZMedicare PIN
NV1194777219OtherINDIVIDUAL NPI
T37196Medicare UPIN