=====================================================
General NPI Number Information
=====================================================
NPI Number | 1538469291
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | JOHN S. MAZELLA, M.D., P.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2010
-----------------------------------------------------
Last Update Date | 10/28/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 37 MOORE AVE
-----------------------------------------------------
City | MOUNT KISCO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10549-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-241-1808
-----------------------------------------------------
Fax | 914-241-4789
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 37 MOORE AVE
-----------------------------------------------------
City | MOUNT KISCO
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10549-3127
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-241-1808
-----------------------------------------------------
Fax | 914-241-4789
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. JOHN SAMUEL MAZELLA
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 914-241-1808
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 092018-1
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------