Provider Demographics
NPI:1639103617
Name:MAZZAGLIA, PETER JOSEPH (MD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:JOSEPH
Last Name:MAZZAGLIA
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 16149
Mailing Address - Street 2:
Mailing Address - City:RUMFORD
Mailing Address - State:RI
Mailing Address - Zip Code:02916-0697
Mailing Address - Country:US
Mailing Address - Phone:401-453-9625
Mailing Address - Fax:401-435-7069
Practice Address - Street 1:2 DUDLEY ST
Practice Address - Street 2:SUITE 470
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905-3236
Practice Address - Country:US
Practice Address - Phone:401-223-0962
Practice Address - Fax:401-861-1272
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD12186208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI31703-4OtherRHODE ISLAND BCBS
RI7058687Medicaid
RIG00415Medicare UPIN
RI007058687Medicare PIN