Provider Demographics
NPI:1437144946
Name:MAZZULLA, JAMES P (MD)
Entity Type:Individual
Prefix:
First Name:JAMES
Middle Name:P
Last Name:MAZZULLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 689711
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53268-9711
Mailing Address - Country:US
Mailing Address - Phone:414-456-3100
Mailing Address - Fax:414-456-3113
Practice Address - Street 1:2500 W LAYTON AVE
Practice Address - Street 2:SUITE 250
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53221-5420
Practice Address - Country:US
Practice Address - Phone:414-282-2006
Practice Address - Fax:414-281-8704
Is Sole Proprietor?:No
Enumeration Date:2005-09-12
Last Update Date:2008-11-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WI20804207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI30321000Medicaid
WI30321000Medicaid
WIB54897Medicare UPIN
WI738400512Medicare Oscar/Certification
WI684800469Medicare Oscar/Certification