Provider Demographics
NPI:1033109848
Name:MAZZUCA, DOUGLAS EDWARD (DO)
Entity Type:Individual
Prefix:DR
First Name:DOUGLAS
Middle Name:EDWARD
Last Name:MAZZUCA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:48 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:PENNSVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:08070-1754
Mailing Address - Country:US
Mailing Address - Phone:856-678-4800
Mailing Address - Fax:856-678-3630
Practice Address - Street 1:48 N BROADWAY
Practice Address - Street 2:
Practice Address - City:PENNSVILLE
Practice Address - State:NJ
Practice Address - Zip Code:08070-1754
Practice Address - Country:US
Practice Address - Phone:856-678-4800
Practice Address - Fax:856-678-3630
Is Sole Proprietor?:No
Enumeration Date:2005-10-24
Last Update Date:2020-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB04899600207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ342OtherOPERATING ENGINEERS 825
NJ0105577000OtherAMERIHEALTH
NJ223485583OtherTAX ID
NJSA000004901OtherAMERICHOICE
NJ180030900OtherPALMETTO GBA
NJ55179OtherAETNA
NJ223485583OtherBLUE CROSS
NJ342OtherOPERATING ENGINEERS 825
NJ0290590001Medicare NSC
NJMA456069Medicare PIN