Healthcare Provider Details

I. General information

NPI: 1396975652
Provider Name (Legal Business Name): ISSAM MARZOUK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2009
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4305 N MESA ST SUITE A
EL PASO TX
79902-1123
US

IV. Provider business mailing address

4305 N MESA ST STE A
EL PASO TX
79902-1124
US

V. Phone/Fax

Practice location:
  • Phone: 915-532-2477
  • Fax: 915-532-2470
Mailing address:
  • Phone: 915-532-2477
  • Fax: 915-532-2470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RP1001X
TaxonomyPulmonary Disease Physician
License NumberQ6345
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberRS2014-0452
License Number StateNM
# 3
Primary TaxonomyY
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberQ6345
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: