Provider Demographics
NPI:1649292681
Name:MAZAT, BRUCE ARTHUR (MD)
Entity type:Individual
Prefix:
First Name:BRUCE
Middle Name:ARTHUR
Last Name:MAZAT
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 1:10084 LAKEVIEW RD
Mailing Address - Street 2:
Mailing Address - City:ABERDEEN
Mailing Address - State:MS
Mailing Address - Zip Code:39730-9496
Mailing Address - Country:US
Mailing Address - Phone:662-369-0405
Mailing Address - Fax:
Practice Address - Street 1:10084 LAKEVIEW RD
Practice Address - Street 2:
Practice Address - City:ABERDEEN
Practice Address - State:MS
Practice Address - Zip Code:39730-9496
Practice Address - Country:US
Practice Address - Phone:662-369-0405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2010-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT9827207U00000X
IN01058881A2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
30BDDDJMedicare ID - Type Unspecified
B92604Medicare UPIN