Provider Demographics
NPI:1073827135
Name:MAHFOUZ, RODWAN (MD)
Entity type:Individual
Prefix:DR
First Name:RODWAN
Middle Name:
Last Name:MAHFOUZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 W 57TH ST APT 30Q
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10019-3712
Mailing Address - Country:US
Mailing Address - Phone:248-881-7971
Mailing Address - Fax:
Practice Address - Street 1:587 FIFTH AVE
Practice Address - Street 2:SUITE 801
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10017-8747
Practice Address - Country:US
Practice Address - Phone:212-249-1600
Practice Address - Fax:212-288-0809
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-31
Last Update Date:2020-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 1202902084P0800X
390200000X
NY2724782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL013184700Medicaid
FLIB179YMedicare PIN