Provider Demographics
NPI:1578747663
Name:MAWLA, NAZRE (MD)
Entity Type:Individual
Prefix:
First Name:NAZRE
Middle Name:
Last Name:MAWLA
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 1:1215 S COULTER ST
Mailing Address - Street 2:SUITE 201
Mailing Address - City:AMARILLO
Mailing Address - State:TX
Mailing Address - Zip Code:79106-1758
Mailing Address - Country:US
Mailing Address - Phone:806-358-1671
Mailing Address - Fax:806-358-0168
Practice Address - Street 1:1215 S COULTER ST
Practice Address - Street 2:SUITE 201
Practice Address - City:AMARILLO
Practice Address - State:TX
Practice Address - Zip Code:79106-1758
Practice Address - Country:US
Practice Address - Phone:806-358-1671
Practice Address - Fax:806-358-0168
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-25
Last Update Date:2009-05-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXG1103208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX00AG47OtherBLUE CROSS BLUE SHIELD
TX118791100OtherFIRSTCARE
TXP00626239OtherRR MEDICARE
TX113985903Medicaid
8F21042Medicare PIN
TX00AG47OtherBLUE CROSS BLUE SHIELD