Healthcare Provider Details
I. General information
NPI: 1588799738
Provider Name (Legal Business Name): WIOLETA ELZBIETA MAZURCZAK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N
II. Dates (important events)
Enumeration Date: 02/21/2007
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:
III. Provider practice location address
4400 W 69TH ST STE 1500
SIOUX FALLS SD
57108-8170
US
IV. Provider business mailing address
PO BOX 86370
SIOUX FALLS SD
57118-6370
US
V. Phone/Fax
- Phone: 605-322-5700
- Fax: 605-322-5704
- Phone: 605-322-7510
- Fax: 605-322-6475
VI. Provider taxonomy
Scope of Practice (Provider specialty)
| # 1 | |
| Primary Taxonomy | Y |
| Taxonomy Code | 2084P0804X |
| Taxonomy | Child & Adolescent Psychiatry Physician |
| License Number | 7102 |
| License Number State | SD |
VII. Legacy identifiers
For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:
| # 1 | |
| Identifier | 12200 |
| Identifier Type | MEDICAID |
| Identifier State | ND |
| Identifier Issuer | |
| # 2 | |
| Identifier | 1588799738 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | ARAZ/ AMERICA'S PPO |
| # 3 | |
| Identifier | 708402000 |
| Identifier Type | MEDICAID |
| Identifier State | MN |
| Identifier Issuer | |
| # 4 | |
| Identifier | 7101960 |
| Identifier Type | MEDICAID |
| Identifier State | SD |
| Identifier Issuer | |
| # 5 | |
| Identifier | 412991052723 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | PREFERRED ONE |
| # 6 | |
| Identifier | 4992668 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | BCBS SOUTH DAKOTA |
| # 7 | |
| Identifier | 46022474352 |
| Identifier Type | MEDICAID |
| Identifier State | NE |
| Identifier Issuer | |
| # 8 | |
| Identifier | 040121002 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | PRIMEWEST |
| # 9 | |
| Identifier | 370624200 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | DEPT. OF LABOR |
| # 10 | |
| Identifier | 57108C036 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | WPS TRICARE |
| # 11 | |
| Identifier | 61408 |
| Identifier Type | OTHER |
| Identifier State | |
| Identifier Issuer | SANFORD HEALTH PLAN |
| # 12 | |
| Identifier | 7102 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | DAKOTACARE |
| # 13 | |
| Identifier | HP83890 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | HEALTHPARTNERS |
| # 14 | |
| Identifier | 254722 |
| Identifier Type | OTHER |
| Identifier State | SD |
| Identifier Issuer | MIDLAND'S CHOICE |
| # 15 | |
| Identifier | 6I497MA |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | CC SYSTEMS/ BLUE PLUS |
| # 16 | |
| Identifier | 6I497MA |
| Identifier Type | OTHER |
| Identifier State | MN |
| Identifier Issuer | BLUE PLUS |
VIII. Authorized Official
Name:
Title or Position:
Credential:
Phone:
