Provider Demographics
NPI:1942796792
Name:MAISOON, AMINA
Entity Type:Individual
Prefix:DR
First Name:AMINA
Middle Name:
Last Name:MAISOON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1901 W WESTERN AVE STE B
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46619-3570
Mailing Address - Country:US
Mailing Address - Phone:574-234-9033
Mailing Address - Fax:
Practice Address - Street 1:1901 W WESTERN AVE STE B
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46619-3570
Practice Address - Country:US
Practice Address - Phone:574-234-9033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-05
Last Update Date:2021-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02006502A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine