Provider Demographics
NPI:1447256284
Name:MAZO-MAYORQUIN, JOSSE ANTHONY (MD)
Entity type:Individual
Prefix:DR
First Name:JOSSE
Middle Name:ANTHONY
Last Name:MAZO-MAYORQUIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:315 E NASA BLVD
Mailing Address - Street 2:
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1939
Mailing Address - Country:US
Mailing Address - Phone:321-733-2711
Mailing Address - Fax:321-733-2011
Practice Address - Street 1:1341 MEDICAL PARK DR
Practice Address - Street 2:SUITE 101 A
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3235
Practice Address - Country:US
Practice Address - Phone:321-733-2711
Practice Address - Fax:321-733-2011
Is Sole Proprietor?:No
Enumeration Date:2005-06-27
Last Update Date:2015-02-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME896592084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274625500Medicaid
FL48374ZMedicare PIN
FL274625500Medicaid