Provider Demographics
NPI:1154393098
Name:MAZZA, LORI ANN (OD)
Entity type:Individual
Prefix:DR
First Name:LORI
Middle Name:ANN
Last Name:MAZZA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6802 FOREST HILL BLVD
Mailing Address - Street 2:
Mailing Address - City:GREENACRES
Mailing Address - State:FL
Mailing Address - Zip Code:33413-3353
Mailing Address - Country:US
Mailing Address - Phone:561-439-2020
Mailing Address - Fax:561-642-0445
Practice Address - Street 1:6802 FOREST HILL BLVD
Practice Address - Street 2:
Practice Address - City:GREENACRES
Practice Address - State:FL
Practice Address - Zip Code:33413-3353
Practice Address - Country:US
Practice Address - Phone:561-439-2020
Practice Address - Fax:561-642-0445
Is Sole Proprietor?:No
Enumeration Date:2006-02-04
Last Update Date:2010-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC0002875152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL620803700Medicaid
FL620803700Medicaid
FL20677YMedicare ID - Type Unspecified