Provider Demographics
NPI:1447608104
Name:MAZEN HARAKE, MD PC
Entity Type:Organization
Organization Name:MAZEN HARAKE, MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MAZEN
Authorized Official - Middle Name:SAMIR
Authorized Official - Last Name:HARAKE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:773-230-5000
Mailing Address - Street 1:201 W BIG BEAVER RD
Mailing Address - Street 2:SUITE 1130
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-4152
Mailing Address - Country:US
Mailing Address - Phone:248-524-0620
Mailing Address - Fax:248-524-0934
Practice Address - Street 1:201 W BIG BEAVER RD
Practice Address - Street 2:SUITE 1130
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-4152
Practice Address - Country:US
Practice Address - Phone:248-524-0620
Practice Address - Fax:248-524-0934
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-02
Last Update Date:2016-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301086566208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHH367010Medicare PIN