Provider Demographics
NPI:1417931106
Name:ALKHALISY, MAZEN A (MD)
Entity Type:Individual
Prefix:
First Name:MAZEN
Middle Name:A
Last Name:ALKHALISY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:704 S WEBSTER AVE
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54301-3528
Mailing Address - Country:US
Mailing Address - Phone:920-433-3784
Mailing Address - Fax:
Practice Address - Street 1:704 S WEBSTER AVE
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54301-3528
Practice Address - Country:US
Practice Address - Phone:920-433-3784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2014-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44696207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIH77947Medicare UPIN
WI016500215Medicare Oscar/Certification
WI000050Medicare Oscar/Certification
WI000165Medicare Oscar/Certification
WIH77947Medicare UPIN