Provider Demographics
NPI:1750749974
Name:ZAKWAN MAHJOUB
Entity type:Organization
Organization Name:ZAKWAN MAHJOUB
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-710-1000
Mailing Address - Street 1:811 SOUTH BLVD E.
Mailing Address - Street 2:STE 105
Mailing Address - City:ROCHESTER HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48307-5303
Mailing Address - Country:US
Mailing Address - Phone:248-710-1000
Mailing Address - Fax:248-710-1011
Practice Address - Street 1:811 SOUTH BLVD E STE 105
Practice Address - Street 2:
Practice Address - City:ROCHESTER HILLS
Practice Address - State:MI
Practice Address - Zip Code:48307-5303
Practice Address - Country:US
Practice Address - Phone:248-710-1000
Practice Address - Fax:248-710-1011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-02-02
Last Update Date:2021-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301067249207RC0000X
207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104254136Medicaid
MI104254136Medicaid