Basic Information
Provider Information | |||||||||
NPI: | 1669417143 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ABBOUD | ||||||||
FirstName: | MAZEN | ||||||||
MiddleName: | A | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | DPM | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 38135 MARKET SQ | ||||||||
Address2: |   | ||||||||
City: | ZEPHYRHILLS | ||||||||
State: | FL | ||||||||
PostalCode: | 335427505 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8137801255 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 13417 US HIGHWAY 301 | ||||||||
Address2: | SUITE B | ||||||||
City: | DADE CITY | ||||||||
State: | FL | ||||||||
PostalCode: | 335255446 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8137780440 | ||||||||
FaxNumber: | 8133555019 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/18/2006 | ||||||||
LastUpdateDate: | 08/24/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 08/24/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213ES0103X | PO3233 | FL | Y |   | Podiatric Medicine & Surgery Service Providers | Podiatrist | Foot & Ankle Surgery |
ID Information
ID | Type | State | Issuer | Description | P01170435 | 01 | FL | R&R MEDICARE | OTHER | 340592300 | 05 | FL |   | MEDICAID |