Provider Demographics
NPI:1184667396
Name:MARTIN M MROZEK DPM PROFFESSIONAL
Entity Type:Organization
Organization Name:MARTIN M MROZEK DPM PROFFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MARTIN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MROZEK
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:304-574-2310
Mailing Address - Street 1:PO BOX 957
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25840-0957
Mailing Address - Country:US
Mailing Address - Phone:304-574-2310
Mailing Address - Fax:304-574-2311
Practice Address - Street 1:27 PARSONS LANE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:WV
Practice Address - Zip Code:25840-0957
Practice Address - Country:US
Practice Address - Phone:304-574-2310
Practice Address - Fax:304-574-2311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2009-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV00282213E00000X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
No213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV223203OtherCARELINK
WVDD8123OtherRAILROAD MEDICARE
WV001721892OtherMOUNTAIN STATE BC BS
WV0099788000Medicaid
WV9353371Medicare ID - Type Unspecified
WV223203OtherCARELINK
WV4281890001Medicare NSC