Provider Demographics
NPI:1588651509
Name:MAZUR, SANDRA A (NP)
Entity type:Individual
Prefix:MRS
First Name:SANDRA
Middle Name:A
Last Name:MAZUR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:SANDRA
Other - Middle Name:A
Other - Last Name:SCHULKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:130 N WEBER RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BOLINGBROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60440-1519
Mailing Address - Country:US
Mailing Address - Phone:630-646-5777
Mailing Address - Fax:630-646-5729
Practice Address - Street 1:130 N WEBER RD
Practice Address - Street 2:SUITE 112
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-1564
Practice Address - Country:US
Practice Address - Phone:630-378-3400
Practice Address - Fax:630-378-3449
Is Sole Proprietor?:No
Enumeration Date:2005-10-04
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-001598207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK33715Medicare PIN
P75104Medicare UPIN
ILP00646054Medicare PIN