Provider Demographics
NPI:1134114895
Name:MAZUR, DAVID (DO)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MAZUR
Suffix:
Gender:M
Credentials:DO
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 1969
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1969
Mailing Address - Country:US
Mailing Address - Phone:800-968-6866
Mailing Address - Fax:
Practice Address - Street 1:1055 MEDICAL PARK DR SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-3671
Practice Address - Country:US
Practice Address - Phone:800-968-6866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2010-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI51010091442084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
DM009144OtherBLUE CROSS BLUE SHIELD
MI3361580Medicaid
MIF27410Medicare UPIN
MI0M38750Medicare ID - Type Unspecified
MI0P41930010Medicare Oscar/Certification
MI5410008Medicare PIN