Healthcare Provider Details

I. General information

NPI: 1417009010
Provider Name (Legal Business Name): EDWARD LAWRENCE MAZUCHOWSKI II M.D.,PH.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 10/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234
US

IV. Provider business mailing address

3551 ROGER BROOKE DR
FORT SAM HOUSTON TX
78234-4504
US

V. Phone/Fax

Practice location:
  • Phone: 210-539-8774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number01057843A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License Number01057843A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: