Provider Demographics
NPI:1306809918
Name:MAZZIOTTI, MARK V (MD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:V
Last Name:MAZZIOTTI
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 1:2 GREENWAY PLAZA
Mailing Address - Street 2:SUITE 910
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77046
Mailing Address - Country:US
Mailing Address - Phone:713-798-1750
Mailing Address - Fax:713-798-1144
Practice Address - Street 1:202 CONWAY DR STE 200
Practice Address - Street 2:
Practice Address - City:KALISPELL
Practice Address - State:MT
Practice Address - Zip Code:59901-3153
Practice Address - Country:US
Practice Address - Phone:406-758-7490
Practice Address - Fax:406-758-7080
Is Sole Proprietor?:No
Enumeration Date:2006-04-07
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMED-PHYS-LIC-1004622086S0120X
OK305402086S0120X
TXL24532086S0120X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX154947902Medicaid
OK200122410AMedicaid
TX112545202Medicaid
TX8L0767Medicare PIN
G08927Medicare UPIN
TX154947902Medicaid