Healthcare Provider Details

I. General information

NPI: 1083901367
Provider Name (Legal Business Name): GREGORY ALAN MAZUR DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/07/2011
Last Update Date: 10/25/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9915 TAMIAMI TRL N STE 1
NAPLES FL
34108
US

IV. Provider business mailing address

11711 PASETTO LN APT 405
FORT MYERS FL
33908-2670
US

V. Phone/Fax

Practice location:
  • Phone: 239-566-8800
  • Fax: 239-566-2671
Mailing address:
  • Phone: 757-287-0832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number057638
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number310
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: