Provider Demographics
NPI:1356450381
Name:MAZZA, BRUNO ROBERT (MD)
Entity Type:Individual
Prefix:DR
First Name:BRUNO
Middle Name:ROBERT
Last Name:MAZZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:607-873-1244
Practice Address - Street 1:555 SAINT JOSEPHS BLVD STE M2
Practice Address - Street 2:
Practice Address - City:ELMIRA
Practice Address - State:NY
Practice Address - Zip Code:14901-3223
Practice Address - Country:US
Practice Address - Phone:607-734-7121
Practice Address - Fax:607-734-0614
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY131718207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY102786210Medicaid
NY00584616Medicaid
NYJ400067006Medicare PIN