Provider Demographics
NPI:1861565202
Name:MAZUR, LARISA I (MD)
Entity type:Individual
Prefix:DR
First Name:LARISA
Middle Name:I
Last Name:MAZUR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:216 ELM ST
Mailing Address - Street 2:
Mailing Address - City:THIENSVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53092-1602
Mailing Address - Country:US
Mailing Address - Phone:262-238-9576
Mailing Address - Fax:
Practice Address - Street 1:216 ELM ST
Practice Address - Street 2:
Practice Address - City:THIENSVILLE
Practice Address - State:WI
Practice Address - Zip Code:53092-1602
Practice Address - Country:US
Practice Address - Phone:262-238-9576
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91296207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine