Healthcare Provider Details

I. General information

NPI: 1043259328
Provider Name (Legal Business Name): MITCHELL J MAZUREK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/17/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 GLENDALE BLVD
VALPARAISO IN
46383-3767
US

IV. Provider business mailing address

1101 GLENDALE BLVD
VALPARAISO IN
46383-3767
US

V. Phone/Fax

Practice location:
  • Phone: 219-464-2907
  • Fax: 219-462-1054
Mailing address:
  • Phone: 219-464-2907
  • Fax: 219-462-1054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number01040686A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number01040686A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: