Provider Demographics
NPI:1861571291
Name:MUMTAZ, FARZANA B (MD)
Entity type:Individual
Prefix:DR
First Name:FARZANA
Middle Name:B
Last Name:MUMTAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 MACY DR
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-6343
Mailing Address - Country:US
Mailing Address - Phone:770-640-8814
Mailing Address - Fax:770-640-8815
Practice Address - Street 1:2404 MACY DR
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-6343
Practice Address - Country:US
Practice Address - Phone:770-640-8814
Practice Address - Fax:770-640-8815
Is Sole Proprietor?:No
Enumeration Date:2006-11-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA036419207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000557576BOtherAMERIGROUP HEALTH PLAN
GA000557576BMedicaid
GA319176OtherWELLCARE HEALTH PLAN
GAP00245232OtherRAIL ROAD MEDICARE
GA000557576BOtherPEACH STATE HEALTH PLAN
GAP00245232OtherRAIL ROAD MEDICARE
GA000557576BMedicaid