Provider Demographics
NPI:1497776025
Name:MAZZARA, CHERYL M (MD)
Entity Type:Individual
Prefix:DR
First Name:CHERYL
Middle Name:M
Last Name:MAZZARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:19900 E 10 MILE RD STE 102
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-4412
Mailing Address - Country:US
Mailing Address - Phone:586-776-3366
Mailing Address - Fax:586-776-3369
Practice Address - Street 1:19900 E 10 MILE RD STE 102
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-4412
Practice Address - Country:US
Practice Address - Phone:586-776-3366
Practice Address - Fax:586-776-3369
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-21
Last Update Date:2012-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010515982084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2605015512OtherBCBS
MI2605015512OtherBCBS