Provider Demographics
NPI:1417513474
Name:PORVAZNIK, MARK RAINALDO (DO)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:RAINALDO
Last Name:PORVAZNIK
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1425 S GREENFIELD RD STE 101
Mailing Address - Street 2:
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85206-5505
Mailing Address - Country:US
Mailing Address - Phone:809-645-8004
Mailing Address - Fax:
Practice Address - Street 1:1425 S GREENFIELD RD STE 101
Practice Address - Street 2:
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85206-5505
Practice Address - Country:US
Practice Address - Phone:809-645-8004
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-15
Last Update Date:2024-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ010690207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program