Provider Demographics
NPI:1124082813
Name:MAZDA, RUSSELL F (DO)
Entity type:Individual
Prefix:
First Name:RUSSELL
Middle Name:F
Last Name:MAZDA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 425
Mailing Address - Street 2:
Mailing Address - City:LEDERACH
Mailing Address - State:PA
Mailing Address - Zip Code:19450-0425
Mailing Address - Country:US
Mailing Address - Phone:800-528-0006
Mailing Address - Fax:732-349-6030
Practice Address - Street 1:140 NUTT RD
Practice Address - Street 2:
Practice Address - City:PHOENIXVILLE
Practice Address - State:PA
Practice Address - Zip Code:19460-3906
Practice Address - Country:US
Practice Address - Phone:610-983-1221
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-12
Last Update Date:2011-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS004596L207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0010174790010Medicaid
PA457175OtherHIGHMARK BLUE SHIELD
PAOS004596LOtherHEALTH PARTNERS
PA30021002OtherKEYSTONE MERCY HP
PA8821743OtherCIGNA HMO/PPO
PA0033070000OtherPERSONAL CHOICE/KHPE
PA0033070000OtherAMERIHEALTH/INTERCOUNTY
PAE70785Medicare UPIN
PA0010174790010Medicaid