Provider Demographics
NPI:1376631341
Name:MARK H MAZUR MD & BARRY STATNER MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:MARK H MAZUR MD & BARRY STATNER MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MARK
Authorized Official - Middle Name:H
Authorized Official - Last Name:MAZUR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:805-495-1073
Mailing Address - Street 1:2220 LYNN RD
Mailing Address - Street 2:SUITE 301
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-8005
Mailing Address - Country:US
Mailing Address - Phone:805-495-1073
Mailing Address - Fax:805-495-5836
Practice Address - Street 1:2220 LYNN RD
Practice Address - Street 2:SUITE 301
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-8005
Practice Address - Country:US
Practice Address - Phone:805-495-1073
Practice Address - Fax:805-495-5836
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-11
Last Update Date:2011-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0078460Medicaid
CAZZZ62326ZOtherBLUE SHIELD
CAZZZ62326ZOtherBLUE SHIELD