Provider Demographics
NPI:1376719781
Name:MAZUR, MATTHEW A (DO)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:A
Last Name:MAZUR
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:850 N OTSEGO AVE
Mailing Address - Street 2:SUITE 1
Mailing Address - City:GAYLORD
Mailing Address - State:MI
Mailing Address - Zip Code:49735-1568
Mailing Address - Country:US
Mailing Address - Phone:989-731-7708
Mailing Address - Fax:989-731-7929
Practice Address - Street 1:829 N CENTER AVE
Practice Address - Street 2:SUITE 140
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-1595
Practice Address - Country:US
Practice Address - Phone:989-731-7870
Practice Address - Fax:989-731-7837
Is Sole Proprietor?:No
Enumeration Date:2008-05-06
Last Update Date:2020-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036119681207R00000X
MI510102814207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL2220936OtherBCBS
IL1376719781 1Medicaid
MIOF96004OtherMEDICARE GROUP NUMBER
MIOF96004OtherMEDICARE GROUP NUMBER
IL2220936OtherBCBS