=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720061492
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEHRDAD MAZ III MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/27/2005
-----------------------------------------------------
Last Update Date | 11/20/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3901 RAINBOW BLVD
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-588-6009
-----------------------------------------------------
Fax | 913-588-8182
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3901 RAINBOW BLVD
-----------------------------------------------------
City | KANSAS CITY
-----------------------------------------------------
State | KS
-----------------------------------------------------
Zip | 66160
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 913-588-6009
-----------------------------------------------------
Fax | 913-588-8182
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 34035
-----------------------------------------------------
License Number State | AZ
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 04-34968
-----------------------------------------------------
License Number State | KS
-----------------------------------------------------