Provider Demographics
NPI:1518953850
Name:MAZZA, IDA LOURDES (MD)
Entity Type:Individual
Prefix:
First Name:IDA
Middle Name:LOURDES
Last Name:MAZZA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:711 N SIOUX POINT RD
Mailing Address - Street 2:
Mailing Address - City:NORTH SIOUX CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57049-5099
Mailing Address - Country:US
Mailing Address - Phone:712-294-7468
Mailing Address - Fax:
Practice Address - Street 1:711 N SIOUX POINT RD
Practice Address - Street 2:
Practice Address - City:NORTH SIOUX CITY
Practice Address - State:SD
Practice Address - Zip Code:57049-5099
Practice Address - Country:US
Practice Address - Phone:712-294-7468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2024-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X
FLME133355207RC0000X
PAMD419073207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0019560820003Medicaid
H93157Medicare UPIN
BU895969Medicare ID - Type UnspecifiedGROUP PROVIDER #
PA0019560820003Medicaid