Provider Demographics
NPI:1194704601
Name:MAZZILLI, THOMAS V (MD)
Entity type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:V
Last Name:MAZZILLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:171 TECHNOLOGY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:BOALSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:16827-1530
Mailing Address - Country:US
Mailing Address - Phone:814-237-8627
Mailing Address - Fax:814-238-0083
Practice Address - Street 1:111 MARYS AVE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:NY
Practice Address - Zip Code:12401-5852
Practice Address - Country:US
Practice Address - Phone:845-339-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2010-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1989132085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2067E1OtherEMPIRE BCBS
NY000499970001OtherBCBS NE NY
NY01655361Medicaid
NY402509OtherMVP
NY10063093OtherCDPHP
NY000000075925OtherGHI HMO
NY2065E1OtherEMPIRE BCBS
NY4099576OtherGHI PPO
NY000499970002OtherBCBS NE NY
NY000499970004OtherBCBS NENY
NY361786OtherMVP
NY2067E1OtherEMPIRE BCBS
NYP00102558Medicare ID - Type UnspecifiedRAILROAD MEDICARE
NY4305010Medicare ID - Type Unspecified