Healthcare Provider Details

I. General information

NPI: 1922387620
Provider Name (Legal Business Name): MAHMOUD YASSIN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2011
Last Update Date: 08/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 LACEY RD
FORKED RIVER NJ
08731-4235
US

IV. Provider business mailing address

115 LACEY RD
FORKED RIVER NJ
08731-4235
US

V. Phone/Fax

Practice location:
  • Phone: 609-971-0010
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number25MA04292600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: