Provider Demographics
NPI:1902899719
Name:MAZUR, ANDREW KEITH (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:KEITH
Last Name:MAZUR
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 37189
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21297-3189
Mailing Address - Country:US
Mailing Address - Phone:571-423-5699
Mailing Address - Fax:571-423-5698
Practice Address - Street 1:24430 STONE SPRINGS BLVD STE 400
Practice Address - Street 2:
Practice Address - City:DULLES
Practice Address - State:VA
Practice Address - Zip Code:20166-2268
Practice Address - Country:US
Practice Address - Phone:703-776-5040
Practice Address - Fax:703-776-5047
Is Sole Proprietor?:No
Enumeration Date:2005-08-26
Last Update Date:2023-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM2502225100000X
VA2305205338225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1902899719Medicaid