Healthcare Provider Details

I. General information

NPI: 1710097241
Provider Name (Legal Business Name): DOUGLAS MAZUR MS PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

224 BUTTERNUT ST
WEST BEND WI
53095-4910
US

IV. Provider business mailing address

11501 N PARKVIEW DR
MEQUON WI
53092-1920
US

V. Phone/Fax

Practice location:
  • Phone: 262-365-0650
  • Fax: 262-365-0651
Mailing address:
  • Phone: 262-365-0650
  • Fax: 262-365-0651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number4798
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: