Healthcare Provider Details

I. General information

NPI: 1295836211
Provider Name (Legal Business Name): WADDAH MASKOUN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

IV. Provider business mailing address

2799 W GRAND BLVD
DETROIT MI
48202-2608
US

V. Phone/Fax

Practice location:
  • Phone: 313-916-2417
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number51037
License Number StateWI
# 2
Primary TaxonomyY
Taxonomy Code207RC0001X
TaxonomyClinical Cardiac Electrophysiology Physician
License NumberE-8285
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: