1437119856 NPI number — DR. MARTIN M MROZEK DPM

Table of content: DR. MARTIN M MROZEK DPM (NPI 1437119856)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1437119856 NPI number — DR. MARTIN M MROZEK DPM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MROZEK
Provider First Name:
MARTIN
Provider Middle Name:
M
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
DPM
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:
1437119856
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 957
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FAYETTEVILLE
Provider Business Mailing Address State Name:
WV
Provider Business Mailing Address Postal Code:
25840-0957
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
304-574-2310
Provider Business Mailing Address Fax Number:
304-574-2311

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
27 PARSONS LANE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTEVILLE
Provider Business Practice Location Address State Name:
WV
Provider Business Practice Location Address Postal Code:
25840-0957
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
304-574-2310
Provider Business Practice Location Address Fax Number:
304-574-2311
Provider Enumeration Date:
03/28/2006

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: 213EP1101X , with the licence number:  00282 , registered in the state of WV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0099788000 , issued by the state of ( WV ) . This identifiers is of the category "MEDICAID".
  • Identifier: 353171 . This is a "ALLIANCE PPO" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 223203 . This is a "ADVANTRA" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: P00252983 . This is a "RR MEDICARE" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 001721891 . This is a "MOUNTAIN STATE BC BS" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".
  • Identifier: 4281890001 . This is a "DMERC" identifier , issued by the state of ( WV ) . This identifiers is of the category "OTHER".




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