Provider Demographics
NPI:1720285190
Name:MAZZURCO, JASON DANIEL
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DANIEL
Last Name:MAZZURCO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11844 ROCK LANDING DR STE B
Mailing Address - Street 2:
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-4206
Mailing Address - Country:US
Mailing Address - Phone:757-873-0161
Mailing Address - Fax:757-873-0205
Practice Address - Street 1:11844 ROCK LANDING DR STE B
Practice Address - Street 2:
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606
Practice Address - Country:US
Practice Address - Phone:757-873-0161
Practice Address - Fax:757-873-0205
Is Sole Proprietor?:No
Enumeration Date:2007-06-29
Last Update Date:2021-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101017472207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology