Provider Demographics
NPI:1861764441
Name:ALI, MUJTABA (MD)
Entity type:Individual
Prefix:DR
First Name:MUJTABA
Middle Name:
Last Name:ALI
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:PO BOX 27128
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84127-0128
Mailing Address - Country:US
Mailing Address - Phone:801-507-4384
Mailing Address - Fax:
Practice Address - Street 1:8 TH AVE & C ST
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84143-0001
Practice Address - Country:US
Practice Address - Phone:801-507-4384
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-30
Last Update Date:2017-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT9431515-8017207R00000X
UT9431515-1205208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine