Healthcare Provider Details

I. General information

NPI: 1700868940
Provider Name (Legal Business Name): LAILY MAHOOZI M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2005
Last Update Date: 03/18/2024
Certification Date: 03/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 SECOND ST
CORDOVA AK
99574-2290
US

IV. Provider business mailing address

C/O ILANKA COMMUNITY HEALTH CENTER PO BOX 2290
CORDOVA AK
99574-2290
US

V. Phone/Fax

Practice location:
  • Phone: 907-424-3622
  • Fax: 907-424-3275
Mailing address:
  • Phone: 907-424-3622
  • Fax: 907-424-3275

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number002468
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: