Healthcare Provider Details

I. General information

NPI: 1184460677
Provider Name (Legal Business Name): NICHOLAS MAZZUCA RRA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2024
Last Update Date: 07/03/2024
Certification Date: 07/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3501 JOHNSON ST
HOLLYWOOD FL
33021-5421
US

IV. Provider business mailing address

5769 SW 42ND TER
MIAMI FL
33155-5313
US

V. Phone/Fax

Practice location:
  • Phone: 954-987-2000
  • Fax:
Mailing address:
  • Phone: 786-348-3595
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2471V0106X
TaxonomyVascular-Interventional Technology Radiologic Technologist
License NumberCRT39545
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code243U00000X
TaxonomyRadiology Practitioner Assistant
License NumberRA165
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: