Healthcare Provider Details

I. General information

NPI: 1760757868
Provider Name (Legal Business Name): SUBHA MAZZONE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2012
Last Update Date: 09/14/2020
Certification Date: 09/14/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

33 WHITING HILL RD SUITE 31
BREWER ME
04412
US

IV. Provider business mailing address

300 LONGWOOD AVE
BOSTON MA
02115-5724
US

V. Phone/Fax

Practice location:
  • Phone: 207-973-7478
  • Fax:
Mailing address:
  • Phone: 617-355-6000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License Number31514
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberMD22157
License Number StateME
# 3
Primary TaxonomyY
Taxonomy Code2080P0207X
TaxonomyPediatric Hematology & Oncology Physician
License NumberETL5425
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: