Healthcare Provider Details

I. General information

NPI: 1518058700
Provider Name (Legal Business Name): JOHN ANDREW MRAZIK DDS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3000 COLISEUM DR SUITE 204
HAMPTON VA
23666-5963
US

IV. Provider business mailing address

3000 COLISEUM DR SUITE 204
HAMPTON VA
23666-5963
US

V. Phone/Fax

Practice location:
  • Phone: 757-838-3975
  • Fax: 757-838-0120
Mailing address:
  • Phone: 757-838-3975
  • Fax: 757-838-0120

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1223S0112X
TaxonomyOral and Maxillofacial Surgery (Dentist)
License Number0438000106
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: