Provider Demographics
NPI:1962603068
Name:MAZUR, JUSTIN DAVID (MD)
Entity type:Individual
Prefix:
First Name:JUSTIN
Middle Name:DAVID
Last Name:MAZUR
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 1:138 W HOUSTON ST
Mailing Address - Street 2:APT 3
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10012-2560
Mailing Address - Country:US
Mailing Address - Phone:718-928-5053
Mailing Address - Fax:
Practice Address - Street 1:4802 10TH AVE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11219-2916
Practice Address - Country:US
Practice Address - Phone:718-283-6031
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-29
Last Update Date:2011-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY244263207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA400058495Medicare PIN