Provider Demographics
NPI:1386825750
Name:LAURENCE J. MAZZOTTA MD PC
Entity Type:Organization
Organization Name:LAURENCE J. MAZZOTTA MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PROPRIETOR
Authorized Official - Prefix:
Authorized Official - First Name:LAURENCE
Authorized Official - Middle Name:J
Authorized Official - Last Name:MAZZOTTA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:707-648-3327
Mailing Address - Street 1:480 REDWOOD ST
Mailing Address - Street 2:SUITE 14
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2958
Mailing Address - Country:US
Mailing Address - Phone:707-648-3327
Mailing Address - Fax:707-648-3902
Practice Address - Street 1:480 REDWOOD ST
Practice Address - Street 2:SUITE 14
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2958
Practice Address - Country:US
Practice Address - Phone:707-648-3327
Practice Address - Fax:707-648-3902
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-14
Last Update Date:2010-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG28907207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G289070Medicaid
CAA43906Medicare UPIN
CA00G289070Medicare PIN