Provider Demographics
NPI:1285604934
Name:KHUSAYEM, MAZEN (MD)
Entity type:Individual
Prefix:DR
First Name:MAZEN
Middle Name:
Last Name:KHUSAYEM
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:PO BOX 997
Mailing Address - Street 2:
Mailing Address - City:CLAYTON
Mailing Address - State:NC
Mailing Address - Zip Code:27528-0997
Mailing Address - Country:US
Mailing Address - Phone:919-550-6336
Mailing Address - Fax:919-550-0180
Practice Address - Street 1:301 AMOS ST
Practice Address - Street 2:
Practice Address - City:CLAYTON
Practice Address - State:NC
Practice Address - Zip Code:27520-2644
Practice Address - Country:US
Practice Address - Phone:919-550-6336
Practice Address - Fax:919-550-0180
Is Sole Proprietor?:No
Enumeration Date:2006-01-25
Last Update Date:2007-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9900898207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89126XVMedicaid
NC2280894Medicare ID - Type Unspecified
NC89126XVMedicaid