Basic Information
| Provider Information | |||||||||
| NPI: | 1902905300 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAZIQUE | ||||||||
| FirstName: | JEFFREY | ||||||||
| MiddleName: | CRAIG | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 3RD AVE | ||||||||
| Address2: | |||||||||
| City: | LOUISBURG | ||||||||
| State: | MN | ||||||||
| PostalCode: | 562566008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2406788561 | ||||||||
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| Practice Location | |||||||||
| Address1: | 215 BLOOMINGDALE AVE | ||||||||
| Address2: | |||||||||
| City: | FEDERALSBURG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 216321012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107549021 | ||||||||
| FaxNumber: | 4107545693 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/22/2006 | ||||||||
| 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 | 207R00000X | 12146 | DC | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | D37088 | MD | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.