Basic Information
Provider Information | |||||||||
NPI: | 1316925076 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MAZDAI | ||||||||
FirstName: | ANITA | ||||||||
MiddleName: | K | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1100 SOUTHFIELD DR | ||||||||
Address2: | SUITE 1370 | ||||||||
City: | PLAINFIELD | ||||||||
State: | IN | ||||||||
PostalCode: | 461684498 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3178375571 | ||||||||
FaxNumber: | 3178375580 | ||||||||
Practice Location | |||||||||
Address1: | 6911 E US HIGHWAY 36 | ||||||||
Address2: |   | ||||||||
City: | AVON | ||||||||
State: | IN | ||||||||
PostalCode: | 461238926 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3172728033 | ||||||||
FaxNumber: | 3172728044 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/04/2006 | ||||||||
LastUpdateDate: | 03/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 03/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | 01052830A | IN | Y |   | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |   |
No ID Information.