1073583738 NPI number — RENATA N MAZZEI -KLOKIW MD

Table of content: RENATA N MAZZEI -KLOKIW MD (NPI 1073583738)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073583738 NPI number — RENATA N MAZZEI -KLOKIW MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAZZEI -KLOKIW
Provider First Name:
RENATA
Provider Middle Name:
N
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MAZZEI
Provider Other First Name:
RENATA
Provider Other Middle Name:
NICOLETTA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1073583738
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
103 SITTERLY ROAD
Provider Second Line Business Mailing Address:
SUITE 2300
Provider Business Mailing Address City Name:
CLIFTON PARK
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
12065-1026
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
518-579-2650
Provider Business Mailing Address Fax Number:
518-579-2670

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
103 SITTERLY ROAD
Provider Second Line Business Practice Location Address:
SUITE 2300
Provider Business Practice Location Address City Name:
CLIFTON PARK
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
12065-1026
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
518-579-2650
Provider Business Practice Location Address Fax Number:
518-579-2670
Provider Enumeration Date:
01/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  229963 , registered in the state of NY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 000000084125 . This is a "GHI-HMO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 11316316 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 9744189 . This is a "GHI-PPO" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 000404963001 . This is a "BLUE SHIELD/HEALTHNOW" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 040426006874 . This is a "FIDELIS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 10076504 . This is a "CDPHP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 7843670 . This is a "AETNA" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 400762 . This is a "MVP" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 4282N1 . This is a "BLUE CROSS" identifier , issued by the state of ( NY ) . This identifiers is of the category "OTHER".
  • Identifier: 02600448 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00196354 . This is a "RAILROAD MEDICARE" identifier . This identifiers is of the category "OTHER".




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