Provider Demographics
NPI:1124004320
Name:SHAZLY, MOUNIR A (MD)
Entity Type:Individual
Prefix:
First Name:MOUNIR
Middle Name:A
Last Name:SHAZLY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 171306
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38187-1306
Mailing Address - Country:US
Mailing Address - Phone:800-809-2106
Mailing Address - Fax:334-386-2037
Practice Address - Street 1:1755 KIRBY PKWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38120-8300
Practice Address - Country:US
Practice Address - Phone:901-725-5846
Practice Address - Fax:901-726-4827
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN21093174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3057946Medicaid
TN3057946Medicaid
TND91228Medicare UPIN