Healthcare Provider Details

I. General information

NPI: 1699986760
Provider Name (Legal Business Name): MAZEN SAMIR HARAKE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 10/07/2025
Certification Date: 10/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1050 WILSHIRE DR STE 100
TROY MI
48084-1526
US

IV. Provider business mailing address

1050 WILSHIRE DR STE 100
TROY MI
48084-1526
US

V. Phone/Fax

Practice location:
  • Phone: 773-230-5000
  • Fax: 248-825-3214
Mailing address:
  • Phone: 773-230-5000
  • Fax: 248-825-8214

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number35123751
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: