Provider Demographics
NPI:1730165846
Name:MAZEY, BRYAN J III (DO)
Entity type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:J
Last Name:MAZEY
Suffix:III
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:36821 GREEN ST
Mailing Address - Street 2:
Mailing Address - City:NEW BALTIMORE
Mailing Address - State:MI
Mailing Address - Zip Code:48047-1607
Mailing Address - Country:US
Mailing Address - Phone:586-716-4959
Mailing Address - Fax:586-716-2936
Practice Address - Street 1:36821 GREEN ST
Practice Address - Street 2:
Practice Address - City:NEW BALTIMORE
Practice Address - State:MI
Practice Address - Zip Code:48047-1607
Practice Address - Country:US
Practice Address - Phone:586-716-4959
Practice Address - Fax:586-716-2936
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-20
Last Update Date:2014-05-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101011409207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3508019Medicaid
MIG05192Medicare UPIN
MI3508019Medicaid