Provider Demographics
NPI:1811953391
Name:MAZONSON, PETER D (MD)
Entity type:Individual
Prefix:
First Name:PETER
Middle Name:D
Last Name:MAZONSON
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 1:1036 COLLEGE AVE
Mailing Address - Street 2:
Mailing Address - City:MENLO PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94025-5210
Mailing Address - Country:US
Mailing Address - Phone:650-323-4511
Mailing Address - Fax:
Practice Address - Street 1:500 TULLY RD
Practice Address - Street 2:VHC TULLY PRIMARY CARE CLINIC
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95111-1917
Practice Address - Country:US
Practice Address - Phone:408-494-7400
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61502207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAC89230Medicare UPIN
CA00G615020Medicare ID - Type Unspecified