Provider Demographics
NPI:1982691515
Name:MAKTABI, MAZEN A (MD)
Entity type:Individual
Prefix:
First Name:MAZEN
Middle Name:A
Last Name:MAKTABI
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 1:200 HAWKINS DR
Mailing Address - Street 2:
Mailing Address - City:IOWA CITY
Mailing Address - State:IA
Mailing Address - Zip Code:52242-1009
Mailing Address - Country:US
Mailing Address - Phone:319-356-2633
Mailing Address - Fax:319-356-2940
Practice Address - Street 1:200 HAWKINS DR
Practice Address - Street 2:
Practice Address - City:IOWA CITY
Practice Address - State:IA
Practice Address - Zip Code:52242-1009
Practice Address - Country:US
Practice Address - Phone:319-356-2633
Practice Address - Fax:319-356-2940
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA25902207L00000X
MA246601207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0261388Medicaid
IA26138OtherWELLMARK BCBS
IA050023556Medicare PIN
IA26138Medicare PIN
IA26138OtherWELLMARK BCBS