Provider Demographics
NPI:1275740169
Name:QAZI, MAHNAZ (MD)
Entity Type:Individual
Prefix:
First Name:MAHNAZ
Middle Name:
Last Name:QAZI
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 1:2622 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5410
Mailing Address - Country:US
Mailing Address - Phone:260-425-3100
Mailing Address - Fax:260-425-3604
Practice Address - Street 1:2622 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5410
Practice Address - Country:US
Practice Address - Phone:260-425-3100
Practice Address - Fax:260-425-3604
Is Sole Proprietor?:No
Enumeration Date:2007-05-17
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01068402A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200985520Medicaid
IN150640031Medicare PIN