Provider Demographics
NPI:1083633788
Name:MAZZA, MICHAEL ANTHONY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:ANTHONY
Last Name:MAZZA
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 1:1 HANSON PL
Mailing Address - Street 2:STE 708
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11243-2900
Mailing Address - Country:US
Mailing Address - Phone:718-783-5437
Mailing Address - Fax:718-783-3840
Practice Address - Street 1:1 HANSON PL
Practice Address - Street 2:STE 708
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11243-2900
Practice Address - Country:US
Practice Address - Phone:718-783-5437
Practice Address - Fax:718-783-3840
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY185168174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01241785Medicaid
NYD78399Medicare UPIN