Provider Demographics
NPI:1043259328
Name:MAZUREK, MITCHELL J (MD)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:J
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 1:1101 GLENDALE BLVD
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-3767
Mailing Address - Country:US
Mailing Address - Phone:219-464-2907
Mailing Address - Fax:219-462-1054
Practice Address - Street 1:1101 GLENDALE BLVD
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-3767
Practice Address - Country:US
Practice Address - Phone:219-464-2907
Practice Address - Fax:219-462-1054
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-05
Last Update Date:2014-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040686A225400000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100097710Medicaid
IN100097710Medicaid
INE72831Medicare UPIN