Provider Demographics
NPI:1326098013
Name:RAZA, MAMOON A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMOON
Middle Name:A
Last Name:RAZA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:P.O. BOX 2968
Mailing Address - Street 2:
Mailing Address - City:ELKHART
Mailing Address - State:IN
Mailing Address - Zip Code:46515-2968
Mailing Address - Country:US
Mailing Address - Phone:574-296-3341
Mailing Address - Fax:574-296-3223
Practice Address - Street 1:303 S NAPPANEE ST
Practice Address - Street 2:
Practice Address - City:ELKHART
Practice Address - State:IN
Practice Address - Zip Code:46514-2066
Practice Address - Country:US
Practice Address - Phone:574-296-3341
Practice Address - Fax:574-296-3223
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061775A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN227950C3Medicare PIN
INI68773Medicare UPIN