Healthcare Provider Details

I. General information

NPI: 1326098013
Provider Name (Legal Business Name): MAMOON A. RAZA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 09/19/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

303 S NAPPANEE ST
ELKHART IN
46514-2066
US

IV. Provider business mailing address

P.O. BOX 2968
ELKHART IN
46515-2968
US

V. Phone/Fax

Practice location:
  • Phone: 574-296-3341
  • Fax: 574-296-3223
Mailing address:
  • Phone: 574-296-3341
  • Fax: 574-296-3223

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number01061775A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: