Provider Demographics
NPI:1992980783
Name:SHACKOUR, MAZIN (MD)
Entity type:Individual
Prefix:
First Name:MAZIN
Middle Name:
Last Name:SHACKOUR
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 1:2665 WINGATE WAY NW
Mailing Address - Street 2:APT 4
Mailing Address - City:CANTON
Mailing Address - State:OH
Mailing Address - Zip Code:44708-8945
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1330 MERCY DR NW
Practice Address - Street 2:SUITE 420
Practice Address - City:CANTON
Practice Address - State:OH
Practice Address - Zip Code:44708-2626
Practice Address - Country:US
Practice Address - Phone:330-580-4697
Practice Address - Fax:330-588-4698
Is Sole Proprietor?:No
Enumeration Date:2007-12-31
Last Update Date:2022-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35120787208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0084650Medicaid
OHH199580Medicare PIN