Healthcare Provider Details

I. General information

NPI: 1063020626
Provider Name (Legal Business Name): MAZIN HAZIM KAMIL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2020
Last Update Date: 07/20/2020
Certification Date: 07/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 REMINGTON PLACE CT
BALLWIN MO
63021-6369
US

IV. Provider business mailing address

15 REMINGTON PLACE CT
BALLWIN MO
63021-6369
US

V. Phone/Fax

Practice location:
  • Phone: 94-122-2052
  • Fax:
Mailing address:
  • Phone: 94-122-2052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2018042518
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code207RG0100X
TaxonomyGastroenterology Physician
License Number2018042518
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: