1053351924 NPI number — JEFFREY M MAZURE DO

Table of content: JEFFREY M MAZURE DO (NPI 1053351924)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053351924 NPI number — JEFFREY M MAZURE DO

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAZURE
Provider First Name:
JEFFREY
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DO
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:
1053351924
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/27/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 LAUREL OAK RD STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VOORHEES
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
08043-4455
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
856-922-9894
Provider Business Mailing Address Fax Number:
856-922-9890

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 E REDMAN AVE STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HADDONFIELD
Provider Business Practice Location Address State Name:
NJ
Provider Business Practice Location Address Postal Code:
08033-2316
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
856-428-1335
Provider Business Practice Location Address Fax Number:
856-428-1330
Provider Enumeration Date:
06/07/2006

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:  OS-013105 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Q00000X , with the licence number: MB74824 , registered in the state of NJ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1022848140002 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 1022848140001 , issued by the state of ( PA ) . This identifiers is of the category "MEDICAID".
  • Identifier: CD4829 . This is a "RR MEDICARE GROUP" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".




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