Healthcare Provider Details

I. General information

NPI: 1174611164
Provider Name (Legal Business Name): MAZDA ALAIE D.P.M
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2006
Last Update Date: 05/24/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2015 GRAND CONCOURSE
BRONX NY
10453-4303
US

IV. Provider business mailing address

3198 GRAND CONCOURSE
BRONX NY
10458-1000
US

V. Phone/Fax

Practice location:
  • Phone: 718-299-7295
  • Fax: 718-299-6797
Mailing address:
  • Phone: 718-618-0401
  • Fax: 718-795-4394

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0131X
TaxonomyFoot Surgery Podiatrist
License NumberN005394
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: