Provider Demographics
NPI:1902841927
Name:MUMTAZ, MUHAMMAD ATHAR (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:ATHAR
Last Name:MUMTAZ
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 1:63 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-4342
Mailing Address - Country:US
Mailing Address - Phone:508-559-1567
Mailing Address - Fax:508-559-5073
Practice Address - Street 1:63 MAIN ST
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-4012
Practice Address - Country:US
Practice Address - Phone:505-559-6699
Practice Address - Fax:508-583-4649
Is Sole Proprietor?:No
Enumeration Date:2006-06-17
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA204600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAJ23605OtherBLUE CROSS BLUE SHIELD
0025950OtherNEIGHBORHOOD HEALTH PLAN
MA35780OtherHEALTHY START
MA35780OtherHEALTHY START
MAJ23605OtherBLUE CROSS BLUE SHIELD