Provider Demographics
NPI:1962794560
Name:MAZLOOM, ALI (MD)
Entity type:Individual
Prefix:
First Name:ALI
Middle Name:
Last Name:MAZLOOM
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 1:21216 NORTHWEST FWY STE 100
Mailing Address - Street 2:
Mailing Address - City:CYPRESS
Mailing Address - State:TX
Mailing Address - Zip Code:77429-1439
Mailing Address - Country:US
Mailing Address - Phone:832-912-3650
Mailing Address - Fax:
Practice Address - Street 1:21216 NORTHWEST FWY STE 100
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:TX
Practice Address - Zip Code:77429
Practice Address - Country:US
Practice Address - Phone:832-912-3650
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-14
Last Update Date:2018-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP99052085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX361394501Medicaid