Provider Demographics
NPI:1649292624
Name:MAZEN, WALTER SAM JR (MD)
Entity type:Individual
Prefix:DR
First Name:WALTER
Middle Name:SAM
Last Name:MAZEN
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1665 ESPLANADE
Mailing Address - Street 2:
Mailing Address - City:CHICO
Mailing Address - State:CA
Mailing Address - Zip Code:95926-3312
Mailing Address - Country:US
Mailing Address - Phone:530-895-0423
Mailing Address - Fax:530-895-1872
Practice Address - Street 1:1665 ESPLANADE
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95926-3312
Practice Address - Country:US
Practice Address - Phone:530-895-0423
Practice Address - Fax:530-895-1872
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG45960207VX0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGROO43570Medicaid
CAG45960OtherCALIFORNIA STATE LICENSE
CAG45960OtherCALIFORNIA STATE LICENSE
CAG45960OtherCALIFORNIA STATE LICENSE
CAA50246Medicare UPIN