Provider Demographics
NPI:1619056041
Name:KHALIDI, MAZEN (MD)
Entity Type:Individual
Prefix:
First Name:MAZEN
Middle Name:
Last Name:KHALIDI
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 1:22790 HARPER AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1831
Mailing Address - Country:US
Mailing Address - Phone:586-778-6060
Mailing Address - Fax:586-773-8220
Practice Address - Street 1:22790 HARPER AVE
Practice Address - Street 2:SUITE C
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1831
Practice Address - Country:US
Practice Address - Phone:586-778-6060
Practice Address - Fax:586-773-8220
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301034244208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
E26384Medicare UPIN
MI0500028Medicare ID - Type Unspecified