Provider Demographics
NPI:1710097241
Name:MAZUR, DOUGLAS (MS PT)
Entity Type:Individual
Prefix:
First Name:DOUGLAS
Middle Name:
Last Name:MAZUR
Suffix:
Gender:M
Credentials:MS PT
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Mailing Address - Street 1:11501 N PARKVIEW DR
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1920
Mailing Address - Country:US
Mailing Address - Phone:262-365-0650
Mailing Address - Fax:262-365-0651
Practice Address - Street 1:224 BUTTERNUT ST
Practice Address - Street 2:
Practice Address - City:WEST BEND
Practice Address - State:WI
Practice Address - Zip Code:53095-4910
Practice Address - Country:US
Practice Address - Phone:262-365-0650
Practice Address - Fax:262-365-0651
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4798225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI4798OtherLICENSE NUMBER