=====================================================
General NPI Number Information
=====================================================
NPI Number | 1497865414
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JONATHAN MAZUR MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/30/2006
-----------------------------------------------------
Last Update Date | 01/22/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 101 PAGE ST
-----------------------------------------------------
City | NEW BEDFORD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02740-3464
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-973-5469
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 200 MILL RD STE 180
-----------------------------------------------------
City | FAIRHAVEN
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02719-5255
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 508-973-2000
-----------------------------------------------------
Fax | 508-973-2001
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 12002
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 75545
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 12002
-----------------------------------------------------
License Number State | NH
-----------------------------------------------------
Taxonomy #4
-----------------------------------------------------
Taxonomy Code | 2083X0100X
-----------------------------------------------------
Taxonomy Name | Occupational Medicine Physician
-----------------------------------------------------
License Number | 75545
-----------------------------------------------------
License Number State | MA
-----------------------------------------------------