Provider Demographics
NPI:1770555930
Name:ITANI, MAZEN S (MD)
Entity type:Individual
Prefix:
First Name:MAZEN
Middle Name:S
Last Name:ITANI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:62 CRESTVIEW RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN LAKES
Mailing Address - State:NJ
Mailing Address - Zip Code:07046-1224
Mailing Address - Country:US
Mailing Address - Phone:973-705-7202
Mailing Address - Fax:973-705-7262
Practice Address - Street 1:183 US HIGHWAY 206 STE 2
Practice Address - Street 2:
Practice Address - City:FLANDERS
Practice Address - State:NJ
Practice Address - Zip Code:07836
Practice Address - Country:US
Practice Address - Phone:973-705-7202
Practice Address - Fax:973-705-7262
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-02
Last Update Date:2021-01-19
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA080755002085R0204X, 2086S0129X, 208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery