Provider Demographics
NPI:1922387620
Name:YASSIN, MAHMOUD
Entity Type:Individual
Prefix:
First Name:MAHMOUD
Middle Name:
Last Name:YASSIN
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 1:115 LACEY RD
Mailing Address - Street 2:
Mailing Address - City:FORKED RIVER
Mailing Address - State:NJ
Mailing Address - Zip Code:08731-4235
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:115 LACEY RD
Practice Address - Street 2:
Practice Address - City:FORKED RIVER
Practice Address - State:NJ
Practice Address - Zip Code:08731-4235
Practice Address - Country:US
Practice Address - Phone:609-971-0010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-08-11
Last Update Date:2011-08-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA04292600208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ3214605Medicaid
F04935Medicare UPIN