Provider Demographics
NPI:1205804283
Name:KHATTAB, MAZEN (MD)
Entity type:Individual
Prefix:
First Name:MAZEN
Middle Name:
Last Name:KHATTAB
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 1:10839 E GOLD DUST AVE
Mailing Address - Street 2:
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85259-4842
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2925 W ROSE GARDEN LN STE 110
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-3135
Practice Address - Country:US
Practice Address - Phone:623-265-7215
Practice Address - Fax:833-465-1462
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42859207RX0202X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2561044Medicaid
AZ529099Medicaid
I29055Medicare UPIN
AZZ140003Medicare PIN