Healthcare Provider Details

I. General information

NPI: 1003900051
Provider Name (Legal Business Name): RIDA S MAZAGRI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 05/09/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 MEDICAL CENTER DRIVE SUITE B500
HUNTINGTON WV
25701
US

IV. Provider business mailing address

1600 MEDICAL CENTER DRIVE SUITE B500
HUNTINGTON WV
25701
US

V. Phone/Fax

Practice location:
  • Phone: 304-691-1787
  • Fax: 304-691-8711
Mailing address:
  • Phone: 304-691-1787
  • Fax: 304-691-8711

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License Number21133
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: