Provider Demographics
NPI:1578559779
Name:MAZZA, SAMUEL J (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:J
Last Name:MAZZA
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:PO BOX 1007
Mailing Address - Street 2:
Mailing Address - City:SOUTHWICK
Mailing Address - State:MA
Mailing Address - Zip Code:01077-1007
Mailing Address - Country:US
Mailing Address - Phone:413-569-2120
Mailing Address - Fax:413-569-6493
Practice Address - Street 1:6 DEPOT STREET
Practice Address - Street 2:
Practice Address - City:SOUTHWICK
Practice Address - State:MA
Practice Address - Zip Code:01077
Practice Address - Country:US
Practice Address - Phone:413-569-2120
Practice Address - Fax:413-569-6493
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-22
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33086208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3102271Medicaid
MAM14122Medicare ID - Type Unspecified
MA3102271Medicaid