Provider Demographics
NPI:1235616095
Name:MAZICK, MATTHEW JOSEPH
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JOSEPH
Last Name:MAZICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1523 CHILDRESS ST
Mailing Address - Street 2:
Mailing Address - City:SHEPPARD AFB
Mailing Address - State:TX
Mailing Address - Zip Code:76311-4306
Mailing Address - Country:US
Mailing Address - Phone:478-954-2216
Mailing Address - Fax:
Practice Address - Street 1:527 TUSKEGEE AIRMAN AVE
Practice Address - Street 2:BUILDING 500
Practice Address - City:SHEPPARD AFB
Practice Address - State:TX
Practice Address - Zip Code:76311
Practice Address - Country:US
Practice Address - Phone:940-676-1092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-07-25
Last Update Date:2023-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV3761225100000X
225100000X
GAPT016202225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist