Basic Information
| Provider Information | |||||||||
| NPI: | 1679904338 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MAZEN MADHOUN MD LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6002 WINNBROOK LN | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240187907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403975319 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Practice Location | |||||||||
| Address1: | 6002 WINNBROOK LN | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240187907 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5403975319 | ||||||||
| FaxNumber: | 5403447154 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/06/2013 | ||||||||
| LastUpdateDate: | 12/06/2013 | ||||||||
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| AuthorizedOfficialLastName: | MADHOUN | ||||||||
| AuthorizedOfficialFirstName: | MAZEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 5403975319 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 0101247995 | VA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.