Provider Demographics
NPI:1386645943
Name:MAZUR, BRUCE A (PT DC)
Entity Type:Individual
Prefix:
First Name:BRUCE
Middle Name:A
Last Name:MAZUR
Suffix:
Gender:M
Credentials:PT DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:822 RIO VISTA
Mailing Address - Street 2:
Mailing Address - City:SANTA FE
Mailing Address - State:NM
Mailing Address - Zip Code:87501
Mailing Address - Country:US
Mailing Address - Phone:505-470-6729
Mailing Address - Fax:
Practice Address - Street 1:1401 MACLOVIA
Practice Address - Street 2:SUITE G
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505
Practice Address - Country:US
Practice Address - Phone:505-471-0818
Practice Address - Fax:505-471-0822
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2379225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2379OtherSTATE OF NM REG. AND LIC.
NMNM000651OtherBLUE CROSS BLUE SHIELD