Provider Demographics
NPI:1134419765
Name:MAZUR, NICHOLAS EDWARD (DO)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:EDWARD
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 1:3531 REDWING CT
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-8304
Mailing Address - Country:US
Mailing Address - Phone:773-405-1509
Mailing Address - Fax:
Practice Address - Street 1:5454 HOHMAN AVE
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:IN
Practice Address - Zip Code:46320-1931
Practice Address - Country:US
Practice Address - Phone:219-933-2077
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-16
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02004584A207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program