Provider Demographics
NPI:1477923084
Name:MAZHAWIDZA, WILLIARD (PA)
Entity type:Individual
Prefix:
First Name:WILLIARD
Middle Name:
Last Name:MAZHAWIDZA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13738 CHASE ST
Mailing Address - Street 2:
Mailing Address - City:CROWN POINT
Mailing Address - State:IN
Mailing Address - Zip Code:46307-9774
Mailing Address - Country:US
Mailing Address - Phone:270-244-3829
Mailing Address - Fax:
Practice Address - Street 1:13738 CHASE ST
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-9774
Practice Address - Country:US
Practice Address - Phone:270-244-3829
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-09-25
Last Update Date:2024-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL085006594363A00000X
IN10002653A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000001487932OtherANTHEM
IN000001487672OtherANTHEM
IN000001487669OtherANTHEM
IN300004715Medicaid
KY7100366870Medicaid