Provider Demographics
NPI:1720413917
Name:MAZAIWANA, RUKUDZO DARLINGTON (MD, OTR/L)
Entity Type:Individual
Prefix:DR
First Name:RUKUDZO
Middle Name:DARLINGTON
Last Name:MAZAIWANA
Suffix:
Gender:M
Credentials:MD, OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3310 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-1466
Mailing Address - Country:US
Mailing Address - Phone:803-531-6900
Mailing Address - Fax:803-531-6907
Practice Address - Street 1:3310 MAGNOLIA ST
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-1466
Practice Address - Country:US
Practice Address - Phone:803-531-6900
Practice Address - Fax:803-531-6907
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2022-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCMD61309208D00000X
GAOT002063225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC613091Medicaid