Provider Demographics
NPI:1871775981
Name:RICHARD D. MAFFEZZOLI LLC
Entity type:Organization
Organization Name:RICHARD D. MAFFEZZOLI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE PRIOPRITOR
Authorized Official - Prefix:DR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:D
Authorized Official - Last Name:MAFFEZZOLI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:410-494-1213
Mailing Address - Street 1:19 SEMINARY DR
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21093-4757
Mailing Address - Country:US
Mailing Address - Phone:410-494-1213
Mailing Address - Fax:
Practice Address - Street 1:515 FAIRMOUNT AVE
Practice Address - Street 2:SUITE 330
Practice Address - City:TOWSON
Practice Address - State:MD
Practice Address - Zip Code:21286-5466
Practice Address - Country:US
Practice Address - Phone:410-494-1213
Practice Address - Fax:410-494-1233
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-30
Last Update Date:2011-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDDO7132207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD025571800Medicaid
MDB69617Medicare UPIN