Provider Demographics
NPI:1285681312
Name:KHAYAT, MAZEN JR (MD)
Entity Type:Individual
Prefix:
First Name:MAZEN
Middle Name:
Last Name:KHAYAT
Suffix:JR
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAZEN
Other - Middle Name:
Other - Last Name:KHAYAT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:801 BARRET AVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40204-1747
Mailing Address - Country:US
Mailing Address - Phone:502-589-9310
Mailing Address - Fax:502-583-5560
Practice Address - Street 1:801 BARRET AVE
Practice Address - Street 2:SUITE 104
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40204-1747
Practice Address - Country:US
Practice Address - Phone:502-589-9310
Practice Address - Fax:502-583-5560
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2022-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044238A207R00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200065880Medicaid
IN200065880Medicaid
ING16456Medicare UPIN