1588459812 NPI number — DR. MAZEN MOHAMED GOUDA MD

Table of content: DR. MAZEN MOHAMED GOUDA MD (NPI 1588459812)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588459812 NPI number — DR. MAZEN MOHAMED GOUDA MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GOUDA
Provider First Name:
MAZEN
Provider Middle Name:
MOHAMED
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1588459812
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/09/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
WINTER HALL, 735 FAIRFAX AVE., SUITE 1017C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORFOLK
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
23501
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
757-446-6191
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 FAIRFAX AVE STE 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NORFOLK
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
23507-1914
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
757-446-0377
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/09/2025

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 390200000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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