Provider Demographics
NPI:1679512081
Name:MAHJOUB, MAZEN A (MD)
Entity Type:Individual
Prefix:DR
First Name:MAZEN
Middle Name:A
Last Name:MAHJOUB
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 1:9375 E MARKET ST
Mailing Address - Street 2:SUITE #3
Mailing Address - City:WARREN
Mailing Address - State:OH
Mailing Address - Zip Code:44484-5515
Mailing Address - Country:US
Mailing Address - Phone:330-392-0100
Mailing Address - Fax:
Practice Address - Street 1:9375 E MARKET ST
Practice Address - Street 2:SUITE #3
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44484-5515
Practice Address - Country:US
Practice Address - Phone:330-392-0100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-07-2671M174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2145851Medicaid
OHF-73960Medicare UPIN
OHMAO832432Medicare PIN