Provider Demographics
NPI:1740231216
Name:MAZO, MIKHAIL (MD)
Entity Type:Individual
Prefix:
First Name:MIKHAIL
Middle Name:
Last Name:MAZO
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 1:50/56 BROADLAWN PARK 222
Mailing Address - Street 2:
Mailing Address - City:NEWTON
Mailing Address - State:MA
Mailing Address - Zip Code:02467
Mailing Address - Country:US
Mailing Address - Phone:617-469-2003
Mailing Address - Fax:
Practice Address - Street 1:300 SOUTH ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:MA
Practice Address - Zip Code:02467-3658
Practice Address - Country:US
Practice Address - Phone:617-469-0300
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208421174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist