=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689601288
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARIA MAZZOTTI DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 10/04/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 601 WALNUT ST SUITE 230E
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19106-3323
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-334-4049
-----------------------------------------------------
Fax | 215-462-9722
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3960 LANKENAU AVE
-----------------------------------------------------
City | PHILADELPHIA
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19131-2827
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 215-829-0101
-----------------------------------------------------
Fax | 215-829-4349
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | OS008840L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------