Basic Information
Provider Information | |||||||||
NPI: | 1568445211 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | GARSKOF | ||||||||
FirstName: | MARK | ||||||||
MiddleName: | MITCHELL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2963 W WHITE MOUNTAIN BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKESIDE | ||||||||
State: | AZ | ||||||||
PostalCode: | 859296257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283680765 | ||||||||
FaxNumber: | 9283684540 | ||||||||
Practice Location | |||||||||
Address1: | 2963 W WHITE MOUNTAIN BLVD | ||||||||
Address2: |   | ||||||||
City: | LAKESIDE | ||||||||
State: | AZ | ||||||||
PostalCode: | 859296257 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9283680765 | ||||||||
FaxNumber: | 9283684540 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/28/2005 | ||||||||
LastUpdateDate: | 03/17/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 10885 | AZ | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | AZ0389120 | 01 | AZ | BCBS | OTHER | 200262 | 05 | AZ |   | MEDICAID |