Healthcare Provider Details

I. General information

NPI: 1265848980
Provider Name (Legal Business Name): EMAN MAZLOUM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 11/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 RAWLINS DR
SEAFORD DE
19973-5881
US

IV. Provider business mailing address

1836 SOUTH MACARTHUR BOULEVARD
SPRINGFIELD IL
62704
US

V. Phone/Fax

Practice location:
  • Phone: 302-990-3300
  • Fax:
Mailing address:
  • Phone: 217-789-1403
  • Fax: 217-789-1825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number036143373
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC1-0012625
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: