Healthcare Provider Details

I. General information

NPI: 1245821131
Provider Name (Legal Business Name): MAZEN EL-KOUDSI NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: MAZEN EL KOUDSI NP

II. Dates (important events)

Enumeration Date: 02/02/2021
Last Update Date: 05/11/2021
Certification Date: 05/11/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12940 W WARREN AVE
DEARBORN MI
48126-1535
US

IV. Provider business mailing address

1405 HOLLYWOOD ST
DEARBORN MI
48124-5021
US

V. Phone/Fax

Practice location:
  • Phone: 313-945-8210
  • Fax: 313-945-0729
Mailing address:
  • Phone: 313-523-0681
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number4704343520
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704343520
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number4704343520
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: