Provider Demographics
NPI:1699716381
Name:MEHANNI, MAGED (MD)
Entity type:Individual
Prefix:
First Name:MAGED
Middle Name:
Last Name:MEHANNI
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 205
Mailing Address - Street 2:
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34973-0205
Mailing Address - Country:US
Mailing Address - Phone:863-763-3622
Mailing Address - Fax:
Practice Address - Street 1:1922 HIGHWAY 441 N
Practice Address - Street 2:
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972-1922
Practice Address - Country:US
Practice Address - Phone:863-763-3622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2010-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0070346207R00000X, 207RC0200X, 207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL250950401Medicaid
FL31790OtherBCBS PIN#
FLME0070346OtherLICENSE
FL31790DMedicare PIN
FL250950401Medicaid