Provider Demographics
NPI:1124102389
Name:MAZZA, DANIEL III (DO)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:
Last Name:MAZZA
Suffix:III
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:ONE MEDICAL CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:BIDDEFORD
Mailing Address - State:ME
Mailing Address - Zip Code:04005
Mailing Address - Country:US
Mailing Address - Phone:207-283-7000
Mailing Address - Fax:
Practice Address - Street 1:ONE MEDICAL CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:BIDDEFORD
Practice Address - State:ME
Practice Address - Zip Code:04005
Practice Address - Country:US
Practice Address - Phone:207-294-5050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2012-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH10162207Q00000X
ME1112207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30010895Medicaid
ME1124102389Medicaid
NHRE4650Medicare PIN
NHB58070Medicare UPIN
MERE465003Medicare PIN