Provider Demographics
NPI:1881004745
Name:SOUFI, MAZHAR
Entity Type:Individual
Prefix:
First Name:MAZHAR
Middle Name:
Last Name:SOUFI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29 E 29TH ST
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4654
Mailing Address - Country:US
Mailing Address - Phone:312-753-8692
Mailing Address - Fax:
Practice Address - Street 1:980 W WALNUT ST # 541C
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5188
Practice Address - Country:US
Practice Address - Phone:312-753-8692
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-30
Last Update Date:2021-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01081217A208D00000X
PAMT212218208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice