Provider Demographics
NPI:1558565929
Name:MAZER, KENNETH ROY
Entity Type:Individual
Prefix:MR
First Name:KENNETH
Middle Name:ROY
Last Name:MAZER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PSC 814 BOX 19
Mailing Address - Street 2:
Mailing Address - City:FPO
Mailing Address - State:AE
Mailing Address - Zip Code:09865
Mailing Address - Country:US
Mailing Address - Phone:01130697-207-9805
Mailing Address - Fax:
Practice Address - Street 1:PSC 814 BOX 19
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AE
Practice Address - Zip Code:09865
Practice Address - Country:US
Practice Address - Phone:01130697-207-9805
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman