Provider Demographics
NPI:1194940965
Name:MAZZAFERRO, ALICE
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:MAZZAFERRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85 MAXWELL RD
Mailing Address - Street 2:
Mailing Address - City:MONSON
Mailing Address - State:MA
Mailing Address - Zip Code:01057-9438
Mailing Address - Country:US
Mailing Address - Phone:413-283-4316
Mailing Address - Fax:
Practice Address - Street 1:299 CAREW ST
Practice Address - Street 2:SUITE201
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01104-2301
Practice Address - Country:US
Practice Address - Phone:413-732-4589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA5133156F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156F00000XEye and Vision Services ProvidersTechnician/Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0317624Medicaid
MA0317624Medicaid