Provider Demographics
NPI:1598768327
Name:MAZER, THEODORE M (MD)
Entity Type:Individual
Prefix:DR
First Name:THEODORE
Middle Name:M
Last Name:MAZER
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 1:6699 ALVARADO RD
Mailing Address - Street 2:STE 2209
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-5240
Mailing Address - Country:US
Mailing Address - Phone:619-583-8990
Mailing Address - Fax:619-265-1114
Practice Address - Street 1:6699 ALVARADO RD
Practice Address - Street 2:STE 2209
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5240
Practice Address - Country:US
Practice Address - Phone:619-583-8990
Practice Address - Fax:619-265-1114
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2020-02-19
Deactivation Date:2006-03-17
Deactivation Code:
Reactivation Date:2006-03-31
Provider Licenses
StateLicense IDTaxonomies
CAA43828207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A438280Medicaid
CAA43828OtherSTATE LICIENCE
E07570Medicare UPIN