Provider Demographics
NPI:1518936053
Name:MAZZOCCOLI, VITO (MD)
Entity Type:Individual
Prefix:MR
First Name:VITO
Middle Name:
Last Name:MAZZOCCOLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:73 BLOOMFIELD AVE
Mailing Address - Street 2:1ST FLOOR
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-5311
Mailing Address - Country:US
Mailing Address - Phone:973-403-3200
Mailing Address - Fax:973-403-3250
Practice Address - Street 1:73 BLOOMFIELD AVE
Practice Address - Street 2:1ST FLOOR
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-5311
Practice Address - Country:US
Practice Address - Phone:973-403-3200
Practice Address - Fax:973-403-3250
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-16
Last Update Date:2015-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA072343207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0029483Medicaid
NJ076371Medicare ID - Type UnspecifiedPR.FAM.MED. NUMBER
NJ0029483Medicaid