Provider Demographics
NPI:1417399528
Name:WAZZAN, TAREK (MD)
Entity type:Individual
Prefix:
First Name:TAREK
Middle Name:
Last Name:WAZZAN
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 1:489 STATE ST
Mailing Address - Street 2:NEURODIAGNOSTIC DEPT
Mailing Address - City:BANGOR
Mailing Address - State:ME
Mailing Address - Zip Code:04401-6616
Mailing Address - Country:US
Mailing Address - Phone:207-973-7360
Mailing Address - Fax:207-973-7362
Practice Address - Street 1:489 STATE ST
Practice Address - Street 2:NEURODIAGNOSTIC DEPT
Practice Address - City:BANGOR
Practice Address - State:ME
Practice Address - Zip Code:04401-6616
Practice Address - Country:US
Practice Address - Phone:207-973-7360
Practice Address - Fax:207-973-7362
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD196962084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology