Healthcare Provider Details

I. General information

NPI: 1972678852
Provider Name (Legal Business Name): JILL SUZANNE MAZUREK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2006
Last Update Date: 03/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12065 OLD MERIDIAN ST SUITE 100
CARMEL IN
46032-8773
US

IV. Provider business mailing address

12065 OLD MERIDIAN ST SUITE 100
CARMEL IN
46032-8773
US

V. Phone/Fax

Practice location:
  • Phone: 317-844-5351
  • Fax:
Mailing address:
  • Phone: 317-844-5351
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number01043902
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: