Healthcare Provider Details

I. General information

NPI: 1982808762
Provider Name (Legal Business Name): CLAYTON GREGORY MAZOUE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2007
Last Update Date: 03/21/2025
Certification Date: 03/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7035 SAINT ANDREWS RD
COLUMBIA SC
29212-1177
US

IV. Provider business mailing address

PO BOX 6069
WEST COLUMBIA SC
29171-6069
US

V. Phone/Fax

Practice location:
  • Phone: 803-749-0924
  • Fax:
Mailing address:
  • Phone: 803-791-2203
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD.200841
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number93192
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: