Provider Demographics
NPI:1518909126
Name:MARDINI, MAZEN MUHAMMAD (MD)
Entity Type:Individual
Prefix:MR
First Name:MAZEN
Middle Name:MUHAMMAD
Last Name:MARDINI
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 1:999 S FAIRMONT AVE
Mailing Address - Street 2:#115
Mailing Address - City:LODI
Mailing Address - State:CA
Mailing Address - Zip Code:95240
Mailing Address - Country:US
Mailing Address - Phone:209-334-6325
Mailing Address - Fax:209-334-4651
Practice Address - Street 1:999 S FAIRMONT AVE
Practice Address - Street 2:#115
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240
Practice Address - Country:US
Practice Address - Phone:209-334-6325
Practice Address - Fax:209-334-4651
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2010-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA35332207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
942676155OtherFED ID
CA00A353320Medicaid
CA00A353320Medicaid
A27748Medicare UPIN