Provider Demographics
NPI:1720239106
Name:MAHAN, JOEL BRENNAN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOEL
Middle Name:BRENNAN
Last Name:MAHAN
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 1:1600 PROVIDENCE DR
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76707-2261
Mailing Address - Country:US
Mailing Address - Phone:254-313-4200
Mailing Address - Fax:254-313-4326
Practice Address - Street 1:609 ELM AVE
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76704
Practice Address - Country:US
Practice Address - Phone:254-313-6900
Practice Address - Fax:254-313-6959
Is Sole Proprietor?:No
Enumeration Date:2008-10-03
Last Update Date:2016-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN0937207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX200061401Medicaid
TX200061401Medicaid