Healthcare Provider Details

I. General information

NPI: 1619807567
Provider Name (Legal Business Name): IVAN XAVIER MAZURSKY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/21/2026
Last Update Date: 05/21/2026
Certification Date: 05/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7108 S KANNER HWY
STUART FL
34997-7462
US

IV. Provider business mailing address

5818 HERONVIEW CRESCENT DR
LITHIA FL
33547-5890
US

V. Phone/Fax

Practice location:
  • Phone: 772-349-6317
  • Fax:
Mailing address:
  • Phone: 954-487-7655
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: