Provider Demographics
NPI:1174561872
Name:MARK R. GAZALL, D.O., LLC
Entity type:Organization
Organization Name:MARK R. GAZALL, D.O., LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT.
Authorized Official - Prefix:
Authorized Official - First Name:SCOTT
Authorized Official - Middle Name:E
Authorized Official - Last Name:STEINER
Authorized Official - Suffix:
Authorized Official - Credentials:RT(R)(ARRT)
Authorized Official - Phone:937-458-0085
Mailing Address - Street 1:2141 N. FAIRFIELD RD,
Mailing Address - Street 2:SUITE B.
Mailing Address - City:BREAVER CREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2579
Mailing Address - Country:US
Mailing Address - Phone:937-458-0085
Mailing Address - Fax:937-458-0212
Practice Address - Street 1:2141 N. FAIRFIELD RD,
Practice Address - Street 2:SUITE B.
Practice Address - City:BREAVER CREEK
Practice Address - State:OH
Practice Address - Zip Code:45431-2579
Practice Address - Country:US
Practice Address - Phone:937-458-0085
Practice Address - Fax:937-458-0212
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-03
Last Update Date:2012-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34-005012208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHPENDINGMedicare ID - Type Unspecified