Provider Demographics
NPI:1245821131
Name:EL-KOUDSI, MAZEN (NP)
Entity type:Individual
Prefix:
First Name:MAZEN
Middle Name:
Last Name:EL-KOUDSI
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:MAZEN
Other - Middle Name:
Other - Last Name:EL KOUDSI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:1405 HOLLYWOOD ST
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-5021
Mailing Address - Country:US
Mailing Address - Phone:313-523-0681
Mailing Address - Fax:
Practice Address - Street 1:12940 W WARREN AVE
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-1535
Practice Address - Country:US
Practice Address - Phone:313-945-8210
Practice Address - Fax:313-945-0729
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-02
Last Update Date:2021-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704343520363LA2200X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology