Provider Demographics
NPI:1316903560
Name:DAOUD, MAZEN (MD)
Entity type:Individual
Prefix:DR
First Name:MAZEN
Middle Name:
Last Name:DAOUD
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 1:12580 UNIVERSITY DR
Mailing Address - Street 2:SUITE 200
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5686
Mailing Address - Country:US
Mailing Address - Phone:239-274-0005
Mailing Address - Fax:239-274-8185
Practice Address - Street 1:12580 UNIVERSITY DR
Practice Address - Street 2:SUITE 200
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5686
Practice Address - Country:US
Practice Address - Phone:239-274-0005
Practice Address - Fax:239-274-8185
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-25
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME81133207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL70017117OtherRR MEDICARE PROVIDER #
FL03-00804OtherUNITED HEALTHCARE PROVIDE
FL06492OtherBCBS PROVIDER #
FL2821758OtherAVMED PROVIDER #
FL202599OtherWELLCARE PROVIDER #
FL2821758OtherAETNA PROVIDER #
FL06492OtherBCBS PROVIDER #
FL70017117OtherRR MEDICARE PROVIDER #
FL06492ZMedicare ID - Type UnspecifiedMEDICARE PROVIDER #