Provider Demographics
NPI:1255433041
Name:MAZZATTA, GREGORY JOHN (DPM)
Entity type:Individual
Prefix:MR
First Name:GREGORY
Middle Name:JOHN
Last Name:MAZZATTA
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1145 BEACON AVE
Mailing Address - Street 2:
Mailing Address - City:MANAHAWKIN
Mailing Address - State:NJ
Mailing Address - Zip Code:08050-2471
Mailing Address - Country:US
Mailing Address - Phone:609-597-6688
Mailing Address - Fax:609-597-9907
Practice Address - Street 1:1145 BEACON AVE
Practice Address - Street 2:
Practice Address - City:MANAHAWKIN
Practice Address - State:NJ
Practice Address - Zip Code:08050-2471
Practice Address - Country:US
Practice Address - Phone:609-597-6688
Practice Address - Fax:609-597-9907
Is Sole Proprietor?:No
Enumeration Date:2006-09-02
Last Update Date:2012-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00231500213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7079508Medicaid
NJ7079508Medicaid
NJU59316Medicare UPIN