Healthcare Provider Details

I. General information

NPI: 1598055055
Provider Name (Legal Business Name): MATHEW MAZOCH
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7301 HENNESSY BLVD STE 200
BATON ROUGE LA
70808-4794
US

IV. Provider business mailing address

PO BOX 98035
BATON ROUGE LA
70898-9035
US

V. Phone/Fax

Practice location:
  • Phone: 225-766-0050
  • Fax: 225-766-1499
Mailing address:
  • Phone: 225-766-0050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number303962
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: