Healthcare Provider Details

I. General information

NPI: 1134436819
Provider Name (Legal Business Name): MAZEN DIAB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/02/2010
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17495 LA GRANGE RD
TINLEY PARK IL
60487-7581
US

IV. Provider business mailing address

1860 PAYSHERE CIR
CHICAGO IL
60674-4325
US

V. Phone/Fax

Practice location:
  • Phone: 630-873-8875
  • Fax:
Mailing address:
  • Phone: 630-469-9200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207PT0002X
TaxonomyMedical Toxicology (Emergency Medicine) Physician
License NumberMT198421
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number036-135420
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number036135420
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: