Provider Demographics
NPI:1396975652
Name:MARZOUK, ISSAM (MD)
Entity type:Individual
Prefix:
First Name:ISSAM
Middle Name:
Last Name:MARZOUK
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 1:4305 N MESA ST STE A
Mailing Address - Street 2:
Mailing Address - City:EL PASO
Mailing Address - State:TX
Mailing Address - Zip Code:79902-1124
Mailing Address - Country:US
Mailing Address - Phone:915-532-2477
Mailing Address - Fax:915-532-2470
Practice Address - Street 1:4305 N MESA ST
Practice Address - Street 2:SUITE A
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79902-1123
Practice Address - Country:US
Practice Address - Phone:915-532-2477
Practice Address - Fax:915-532-2470
Is Sole Proprietor?:No
Enumeration Date:2009-07-21
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXQ6345207RP1001X, 207RC0200X
NMRS2014-0452390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX355967601Medicaid