Provider Demographics
NPI:1750435095
Name:MAZZAMURRO, WANDA THERESA (DC)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:THERESA
Last Name:MAZZAMURRO
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 MILK ST
Mailing Address - Street 2:SUITE 1
Mailing Address - City:WESTBOROUGH
Mailing Address - State:MA
Mailing Address - Zip Code:01581-1228
Mailing Address - Country:US
Mailing Address - Phone:508-366-7733
Mailing Address - Fax:508-366-3334
Practice Address - Street 1:108 MILK ST
Practice Address - Street 2:SUITE 1
Practice Address - City:WESTBOROUGH
Practice Address - State:MA
Practice Address - Zip Code:01581-1228
Practice Address - Country:US
Practice Address - Phone:508-366-7733
Practice Address - Fax:508-366-3334
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA1421111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAT92083Medicare UPIN
MA1750435095Medicare PIN