Healthcare Provider Details

I. General information

NPI: 1780637108
Provider Name (Legal Business Name): MICHAEL S MAZUREK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2006
Last Update Date: 12/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

702 BARNHILL DR
INDIANAPOLIS IN
46202-5128
US

IV. Provider business mailing address

1120 SOUTH DR FESLER HALL, RM. 204
INDIANAPOLIS IN
46202-5135
US

V. Phone/Fax

Practice location:
  • Phone: 317-274-0273
  • Fax: 317-567-2191
Mailing address:
  • Phone: 317-274-0273
  • Fax: 317-567-2191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number01050827
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207LP3000X
TaxonomyPediatric Anesthesiology Physician
License Number01050827
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: