1598768327 NPI number — DR. THEODORE M. MAZER M.D.

Table of content: (NPI 1366879710)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598768327 NPI number — DR. THEODORE M. MAZER M.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAZER
Provider First Name:
THEODORE
Provider Middle Name:
M.
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598768327
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
03/17/2006
NPI Reactivation Date:
03/31/2006

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6699 ALVARADO RD
Provider Second Line Business Mailing Address:
STE 2209
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92120-5240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
619-583-8990
Provider Business Mailing Address Fax Number:
619-265-1114

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6699 ALVARADO RD
Provider Second Line Business Practice Location Address:
STE 2209
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92120-5240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
619-583-8990
Provider Business Practice Location Address Fax Number:
619-265-1114
Provider Enumeration Date:
05/24/2005

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: 207Y00000X , with the licence number:  A43828 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 00A438280 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".
  • Identifier: A43828 . This is a "STATE LICIENCE" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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