Provider Demographics
NPI:1043242431
Name:MAZDZER, EDWARD J (MD)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:MAZDZER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:206 CORNELIA ST
Mailing Address - Street 2:STE 102
Mailing Address - City:PLATTSBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12901-2779
Mailing Address - Country:US
Mailing Address - Phone:518-314-3344
Mailing Address - Fax:518-314-3468
Practice Address - Street 1:2249 STATE ROUTE 86 STE 1
Practice Address - Street 2:
Practice Address - City:SARANAC LAKE
Practice Address - State:NY
Practice Address - Zip Code:12983-5644
Practice Address - Country:US
Practice Address - Phone:518-891-9795
Practice Address - Fax:518-891-6302
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-07
Last Update Date:2016-08-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY1891592084N0400X
MA485392084N0400X
VT96282084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01013703Medicaid
NY01013703Medicaid
NYCC1026Medicare ID - Type UnspecifiedPROVIDER ID