Provider Demographics
NPI:1265650063
Name:MAZZA, DOMINIC LOUIS (MD)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:LOUIS
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 1:398 KENNEDY DR
Mailing Address - Street 2:
Mailing Address - City:ARCHBALD
Mailing Address - State:PA
Mailing Address - Zip Code:18403-1582
Mailing Address - Country:US
Mailing Address - Phone:570-876-1663
Mailing Address - Fax:570-876-8223
Practice Address - Street 1:398 KENNEDY DR
Practice Address - Street 2:
Practice Address - City:ARCHBALD
Practice Address - State:PA
Practice Address - Zip Code:18403-1582
Practice Address - Country:US
Practice Address - Phone:570-876-1663
Practice Address - Fax:570-876-8223
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2016-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA04318E2084P0015X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0015XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychosomatic Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC89090Medicare UPIN
PA623467Medicare ID - Type Unspecified