Provider Demographics
NPI:1033223235
Name:MAZUREK, DOUGLAS ADOLPH (MD)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:ADOLPH
Last Name:MAZUREK
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 1:2022 KELLE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERTON
Mailing Address - State:IN
Mailing Address - Zip Code:46304-8708
Mailing Address - Country:US
Mailing Address - Phone:219-364-3616
Mailing Address - Fax:219-364-3610
Practice Address - Street 1:1101 GLENDALE BLVD
Practice Address - Street 2:SUITE 103
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3767
Practice Address - Country:US
Practice Address - Phone:219-464-9054
Practice Address - Fax:219-465-1749
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2020-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01038566207RC0200X, 207RP1001X
IN01038566A174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200016720Medicaid
IN200016720Medicaid
IN237880Medicare PIN