Provider Demographics
NPI:1073583738
Name:MAZZEI -KLOKIW, RENATA N (MD)
Entity Type:Individual
Prefix:
First Name:RENATA
Middle Name:N
Last Name:MAZZEI -KLOKIW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:RENATA
Other - Middle Name:NICOLETTA
Other - Last Name:MAZZEI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:103 SITTERLY ROAD
Mailing Address - Street 2:SUITE 2300
Mailing Address - City:CLIFTON PARK
Mailing Address - State:NY
Mailing Address - Zip Code:12065-1026
Mailing Address - Country:US
Mailing Address - Phone:518-579-2650
Mailing Address - Fax:518-579-2670
Practice Address - Street 1:103 SITTERLY ROAD
Practice Address - Street 2:SUITE 2300
Practice Address - City:CLIFTON PARK
Practice Address - State:NY
Practice Address - Zip Code:12065-1026
Practice Address - Country:US
Practice Address - Phone:518-579-2650
Practice Address - Fax:518-579-2670
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2018-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY229963207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY000000084125OtherGHI-HMO
11316316OtherCAQH
NY9744189OtherGHI-PPO
NY000404963001OtherBLUE SHIELD/HEALTHNOW
NY040426006874OtherFIDELIS
NY10076504OtherCDPHP
NY7843670OtherAETNA
NY400762OtherMVP
NY4282N1OtherBLUE CROSS
NY02600448Medicaid
P00196354OtherRAILROAD MEDICARE
NY4282N1OtherBLUE CROSS
NY9744189OtherGHI-PPO
11316316OtherCAQH