Provider Demographics
NPI:1902905300
Name:MAZIQUE, JEFFREY CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:CRAIG
Last Name:MAZIQUE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 3RD AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISBURG
Mailing Address - State:MN
Mailing Address - Zip Code:56256-6008
Mailing Address - Country:US
Mailing Address - Phone:240-678-8561
Mailing Address - Fax:
Practice Address - Street 1:215 BLOOMINGDALE AVE
Practice Address - Street 2:
Practice Address - City:FEDERALSBURG
Practice Address - State:MD
Practice Address - Zip Code:21632-1012
Practice Address - Country:US
Practice Address - Phone:410-754-9021
Practice Address - Fax:410-754-5693
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DC12146207R00000X
MDD37088207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FO54543Medicare UPIN