Provider Demographics
NPI:1073629648
Name:MAZZA, MARY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARY ANN
Middle Name:
Last Name:MAZZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12702 FALLING WATER BLVD
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-9597
Mailing Address - Country:US
Mailing Address - Phone:260-637-2484
Mailing Address - Fax:
Practice Address - Street 1:1700 EAST 38TH ST.
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IN
Practice Address - Zip Code:46953
Practice Address - Country:US
Practice Address - Phone:765-674-3321
Practice Address - Fax:765-677-3149
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-23
Last Update Date:2013-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01026311A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
INC 25313Medicare UPIN