Provider Demographics
NPI:1659323608
Name:KHALIL, MAZEN (MD)
Entity Type:Individual
Prefix:
First Name:MAZEN
Middle Name:
Last Name:KHALIL
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 1:300 CARSON ST
Mailing Address - Street 2:
Mailing Address - City:JONESBORO
Mailing Address - State:AR
Mailing Address - Zip Code:72401-3104
Mailing Address - Country:US
Mailing Address - Phone:870-932-5296
Mailing Address - Fax:870-910-7713
Practice Address - Street 1:300 CARSON ST
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-3104
Practice Address - Country:US
Practice Address - Phone:870-932-5296
Practice Address - Fax:870-910-7713
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2008-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN40968207RH0003X
ARE-5722207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3338867Medicare ID - Type UnspecifiedMEDICARE
AR5H323Medicare PIN