Provider Demographics
NPI:1255311619
Name:MAZUR, ALFRED WALTER (MD)
Entity Type:Individual
Prefix:DR
First Name:ALFRED
Middle Name:WALTER
Last Name:MAZUR
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1377
Mailing Address - Street 2:
Mailing Address - City:DOUGLAS
Mailing Address - State:GA
Mailing Address - Zip Code:31534-1377
Mailing Address - Country:US
Mailing Address - Phone:912-384-1477
Mailing Address - Fax:912-384-1470
Practice Address - Street 1:200 DOCTORS DR
Practice Address - Street 2:SUITE 220
Practice Address - City:DOUGLAS
Practice Address - State:GA
Practice Address - Zip Code:31533-2201
Practice Address - Country:US
Practice Address - Phone:912-384-4030
Practice Address - Fax:912-384-4039
Is Sole Proprietor?:No
Enumeration Date:2006-01-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA046695208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA11D1105865OtherCLIA ID - 17 JOHNSON ST
GA046695OtherPHYSICIAN LICENSE #
GA477420OtherWELLCARE
GA000833412DMedicaid
GA000833412EMedicaid
GA11D1092458OtherCLIA ID - 200 DOCTORS DR STE 220
GADH1281OtherRAILROAD MEDICARE - GROUP #
GAP00726011OtherRAILROAD MEDICARE - PTAN
GAP00726011OtherRAILROAD MEDICARE - PTAN
GAP00726011OtherRAILROAD MEDICARE - PTAN
GADH1281OtherRAILROAD MEDICARE - GROUP #
GA046695OtherPHYSICIAN LICENSE #