Basic Information
| Provider Information | |||||||||
| NPI: | 1053351924 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZURE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | M | ||||||||
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| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 LAUREL OAK RD STE 105 | ||||||||
| Address2: | |||||||||
| City: | VOORHEES | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080434455 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8569229894 | ||||||||
| FaxNumber: | 8569229890 | ||||||||
| Practice Location | |||||||||
| Address1: | 15 E REDMAN AVE STE A | ||||||||
| Address2: | |||||||||
| City: | HADDONFIELD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 080332316 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8564281335 | ||||||||
| FaxNumber: | 8564281330 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 09/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | OS-013105 | PA | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | MB74824 | NJ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1022848140002 | 05 | PA | MEDICAID | 1022848140001 | 05 | PA | MEDICAID | CD4829 | 01 | PA | RR MEDICARE GROUP | OTHER |