Provider Demographics
NPI:1265848980
Name:MAZLOUM, EMAN (MD)
Entity Type:Individual
Prefix:
First Name:EMAN
Middle Name:
Last Name:MAZLOUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1836 SOUTH MACARTHUR BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62704
Mailing Address - Country:US
Mailing Address - Phone:217-789-1403
Mailing Address - Fax:217-789-1825
Practice Address - Street 1:100 RAWLINS DR
Practice Address - Street 2:
Practice Address - City:SEAFORD
Practice Address - State:DE
Practice Address - Zip Code:19973-5881
Practice Address - Country:US
Practice Address - Phone:302-990-3300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-02
Last Update Date:2018-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036143373207Q00000X
DEC1-0012625207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE207Q00000XMedicaid