Provider Demographics
NPI:1801888904
Name:YONAN, MAZIN PUTRUS (MD)
Entity type:Individual
Prefix:
First Name:MAZIN
Middle Name:PUTRUS
Last Name:YONAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MAZIN
Other - Middle Name:PUTRUS
Other - Last Name:AUDISH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2221 LIVERNOIS RD
Mailing Address - Street 2:100
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48083-1603
Mailing Address - Country:US
Mailing Address - Phone:248-250-9474
Mailing Address - Fax:248-250-9483
Practice Address - Street 1:2221 LIVERNOIS RD
Practice Address - Street 2:100
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48083-1603
Practice Address - Country:US
Practice Address - Phone:248-250-9474
Practice Address - Fax:248-250-9483
Is Sole Proprietor?:No
Enumeration Date:2005-08-16
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMY075033207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI409819410Medicaid
MI0F36477100Medicare ID - Type Unspecified
MI409819410Medicaid