Basic Information
Provider Information
NPI: 1033559554
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: MAZURSKY
FirstName: KONSTANTIN
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: D.O
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 1800 E FLORENCE BLVD
Address2:  
City: CASA GRANDE
State: AZ
PostalCode: 851225303
CountryCode: US
TelephoneNumber: 5203816300
FaxNumber:  
Practice Location
Address1: 1800 E FLORENCE BLVD
Address2: BANNER CASA GRANDE
City: CASA GRANDE
State: AZ
PostalCode: 85122
CountryCode: US
TelephoneNumber: 5203816300
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/28/2013
LastUpdateDate: 07/22/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X006870AZY Allopathic & Osteopathic PhysiciansInternal Medicine 
207R00000XR2317AZN Allopathic & Osteopathic PhysiciansInternal Medicine 

No ID Information.


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