Provider Demographics
NPI:1164664751
Name:JOSEPH F MAZZA JR MD PA
Entity Type:Organization
Organization Name:JOSEPH F MAZZA JR MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOSPEH
Authorized Official - Middle Name:F
Authorized Official - Last Name:MAZZA
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:239-482-7676
Mailing Address - Street 1:12640 CREEKSIDE LN
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33919-3359
Mailing Address - Country:US
Mailing Address - Phone:239-482-7676
Mailing Address - Fax:239-482-7604
Practice Address - Street 1:12640 CREEKSIDE LN
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33919-3359
Practice Address - Country:US
Practice Address - Phone:239-482-7676
Practice Address - Fax:239-482-7604
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-30
Last Update Date:2009-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE21433Medicare UPIN