=====================================================
General NPI Number Information
=====================================================
NPI Number | 1164502753
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAZRE MAWLA MD PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/17/2006
-----------------------------------------------------
Last Update Date | 05/09/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1215 S COULTER ST SUITE 201
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-358-1671
-----------------------------------------------------
Fax | 806-358-0168
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1215 S COULTER ST SUITE 201
-----------------------------------------------------
City | AMARILLO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 79106-1758
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 806-358-1671
-----------------------------------------------------
Fax | 806-358-0168
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER OFFICIER
-----------------------------------------------------
Name | NAZRE MAWLA
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 806-358-1671
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | G1103
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------