Healthcare Provider Details

I. General information

NPI: 1396382107
Provider Name (Legal Business Name): HEBA MAHJOUB
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/01/2019
Last Update Date: 07/23/2026
Certification Date: 07/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 TREMONT ST
BOSTON MA
02116-5603
US

IV. Provider business mailing address

260 TREMONT ST
BOSTON MA
02116-5603
US

V. Phone/Fax

Practice location:
  • Phone: 617-636-4600
  • Fax:
Mailing address:
  • Phone: 617-636-4600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number1027839
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: