Basic Information
| Provider Information | |||||||||
| NPI: | 1124102389 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAZZA | ||||||||
| FirstName: | DANIEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072837000 | ||||||||
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| Practice Location | |||||||||
| Address1: | ONE MEDICAL CENTER DRIVE | ||||||||
| Address2: | |||||||||
| City: | BIDDEFORD | ||||||||
| State: | ME | ||||||||
| PostalCode: | 04005 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2072945050 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/24/2006 | ||||||||
| LastUpdateDate: | 10/25/2012 | ||||||||
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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 | 10162 | NH | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 1112 | ME | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 30010895 | 05 | NH | MEDICAID | 1124102389 | 05 | ME | MEDICAID |