Provider Demographics
NPI:1801090006
Name:MAZZARULLI, ANTHONY A (MD)
Entity type:Individual
Prefix:DR
First Name:ANTHONY
Middle Name:A
Last Name:MAZZARULLI
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 1:1601 CUMMINS DR STE D
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95358-6411
Mailing Address - Country:US
Mailing Address - Phone:510-900-3125
Mailing Address - Fax:
Practice Address - Street 1:1601 CUMMINS DR STE D
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95358-6411
Practice Address - Country:US
Practice Address - Phone:510-900-3125
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-12
Last Update Date:2022-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC1475082084N0400X, 2084P0800X
NC2010-020912084N0400X, 2084P0800X
ORMD1801632084N0400X
TXM67522084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1801090006Medicaid
TX194605502Medicaid
BP1-0026742OtherINSTITUTIONAL PERMIT
NC5916730Medicaid
SCNC1329Medicaid
NC1801090006Medicaid
TX8L15507Medicare PIN
TX8L2599Medicare PIN
NC2077145AMedicare PIN