Provider Demographics
NPI:1659599488
Name:REBANE-MAZZOTTA, MARI (MD)
Entity Type:Individual
Prefix:
First Name:MARI
Middle Name:
Last Name:REBANE-MAZZOTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MARI
Other - Middle Name:
Other - Last Name:REBANE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:535 SAYBROOK RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLETOWN
Mailing Address - State:CT
Mailing Address - Zip Code:06457-4743
Mailing Address - Country:US
Mailing Address - Phone:860-343-0122
Mailing Address - Fax:
Practice Address - Street 1:535 SAYBROOK RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:CT
Practice Address - Zip Code:06457-4743
Practice Address - Country:US
Practice Address - Phone:860-343-0122
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-24
Last Update Date:2011-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0494372086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery