Healthcare Provider Details

I. General information

NPI: 1770555930
Provider Name (Legal Business Name): MAZEN S. ITANI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 01/19/2021
Certification Date: 01/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

183 US HIGHWAY 206 STE 2
FLANDERS NJ
07836
US

IV. Provider business mailing address

62 CRESTVIEW RD
MOUNTAIN LAKES NJ
07046-1224
US

V. Phone/Fax

Practice location:
  • Phone: 973-705-7202
  • Fax: 973-705-7262
Mailing address:
  • Phone: 973-705-7202
  • Fax: 973-705-7262

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License Number25MA08075500
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code2086S0129X
TaxonomyVascular Surgery Physician
License Number25MA08075500
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number25MA08075500
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: