Provider Demographics
NPI:1649200106
Name:MAZUR, KIMBERLY L (MD)
Entity Type:Individual
Prefix:DR
First Name:KIMBERLY
Middle Name:L
Last Name:MAZUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1401 ATLANTIC AVE
Mailing Address - Street 2:SUITE 2800
Mailing Address - City:ATLANTIC CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:08401-7022
Mailing Address - Country:US
Mailing Address - Phone:609-441-8036
Mailing Address - Fax:609-572-6021
Practice Address - Street 1:1401 ATLANTIC AVE
Practice Address - Street 2:SUITE 2800
Practice Address - City:ATLANTIC CITY
Practice Address - State:NJ
Practice Address - Zip Code:08401-7022
Practice Address - Country:US
Practice Address - Phone:609-441-8036
Practice Address - Fax:609-572-6021
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2014-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA05995100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ5614104Medicaid
NJ150958CN9Medicare PIN
NJF66366Medicare UPIN
NJMA150958Medicare ID - Type Unspecified