Healthcare Provider Details

I. General information

NPI: 1871775981
Provider Name (Legal Business Name): RICHARD D. MAFFEZZOLI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2007
Last Update Date: 04/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 FAIRMOUNT AVE SUITE 330
TOWSON MD
21286-5466
US

IV. Provider business mailing address

19 SEMINARY DR
LUTHERVILLE MD
21093-4757
US

V. Phone/Fax

Practice location:
  • Phone: 410-494-1213
  • Fax: 410-494-1233
Mailing address:
  • Phone: 410-494-1213
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License NumberDO7132
License Number StateMD

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier025571800
Identifier TypeMEDICAID
Identifier StateMD
Identifier Issuer

VIII. Authorized Official

Name: DR. RICHARD D MAFFEZZOLI
Title or Position: SOLE PRIOPRITOR
Credential: M.D.
Phone: 410-494-1213