=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730631318
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MAZEN SANOUFA MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/28/2016
-----------------------------------------------------
Last Update Date | 08/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1475 W 49TH PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-558-2500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1475 W 49TH PL
-----------------------------------------------------
City | HIALEAH
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33012-3113
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 305-615-7334
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RN0300X
-----------------------------------------------------
Taxonomy Name | Nephrology Physician
-----------------------------------------------------
License Number | TRN36314
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------