Healthcare Provider Details

I. General information

NPI: 1164664751
Provider Name (Legal Business Name): JOSEPH F MAZZA JR MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2009
Last Update Date: 03/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12640 CREEKSIDE LN
FORT MYERS FL
33919-3359
US

IV. Provider business mailing address

12640 CREEKSIDE LN
FORT MYERS FL
33919-3359
US

V. Phone/Fax

Practice location:
  • Phone: 239-482-7676
  • Fax: 239-482-7604
Mailing address:
  • Phone: 239-482-7676
  • Fax: 239-482-7604

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: JOSPEH F MAZZA JR.
Title or Position: PRESIDENT
Credential: MD
Phone: 239-482-7676