Provider Demographics
NPI:1912554460
Name:SOUS, MINA MAHER (MD)
Entity Type:Individual
Prefix:
First Name:MINA
Middle Name:MAHER
Last Name:SOUS
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 1:355 RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:EVANSTON
Mailing Address - State:IL
Mailing Address - Zip Code:60202-3328
Mailing Address - Country:US
Mailing Address - Phone:847-316-4000
Mailing Address - Fax:
Practice Address - Street 1:4755 OGLETOWN STANTON RD STE 5A43
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19718-3328
Practice Address - Country:US
Practice Address - Phone:302-623-0188
Practice Address - Fax:302-733-5640
Is Sole Proprietor?:No
Enumeration Date:2019-08-20
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC1-0025021207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine