Provider Demographics
NPI:1588610026
Name:MAZZELLA, JOHN LOUIS (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:LOUIS
Last Name:MAZZELLA
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 161180
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32716-1180
Mailing Address - Country:US
Mailing Address - Phone:904-388-6949
Mailing Address - Fax:904-388-1841
Practice Address - Street 1:4201 BELFORT RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-1431
Practice Address - Country:US
Practice Address - Phone:904-296-3886
Practice Address - Fax:904-551-0709
Is Sole Proprietor?:No
Enumeration Date:2006-05-26
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME890032085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL270834500Medicaid
FL270834500Medicaid