Provider Demographics
NPI:1376202861
Name:MAHGOUB, FAYIZ (OD)
Entity Type:Individual
Prefix:
First Name:FAYIZ
Middle Name:
Last Name:MAHGOUB
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W PROSPECT RD APT 33B
Mailing Address - Street 2:
Mailing Address - City:FORT COLLINS
Mailing Address - State:CO
Mailing Address - Zip Code:80526-2052
Mailing Address - Country:US
Mailing Address - Phone:970-402-5789
Mailing Address - Fax:
Practice Address - Street 1:5305 SPINE RD STE B
Practice Address - Street 2:
Practice Address - City:BOULDER
Practice Address - State:CO
Practice Address - Zip Code:80301-3331
Practice Address - Country:US
Practice Address - Phone:970-402-5789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-11
Last Update Date:2021-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program