Healthcare Provider Details

I. General information

NPI: 1679628036
Provider Name (Legal Business Name): MICHEL J. MAZOUZ M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/24/2007
Last Update Date: 07/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 S BEVERLY DR STE 730
LOS ANGELES CA
90035-1180
US

IV. Provider business mailing address

PO BOX 67218
LOS ANGELES CA
90067-0218
US

V. Phone/Fax

Practice location:
  • Phone: 310-201-0626
  • Fax: 310-277-2852
Mailing address:
  • Phone: 310-201-0626
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA44045
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: