Healthcare Provider Details

I. General information

NPI: 1902899719
Provider Name (Legal Business Name): ANDREW KEITH MAZUR DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2005
Last Update Date: 01/09/2023
Certification Date: 01/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24430 STONE SPRINGS BLVD STE 400
DULLES VA
20166-2268
US

IV. Provider business mailing address

PO BOX 37189
BALTIMORE MD
21297-3189
US

V. Phone/Fax

Practice location:
  • Phone: 703-776-5040
  • Fax: 703-776-5047
Mailing address:
  • Phone: 571-423-5699
  • Fax: 571-423-5698

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2502
License Number StateNM
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305205338
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: