Provider Demographics
NPI:1861780090
Name:MUKHTAR, JALAL (MD)
Entity type:Individual
Prefix:
First Name:JALAL
Middle Name:
Last Name:MUKHTAR
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 1:210 QUINCY AVE
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02302-2862
Mailing Address - Country:US
Mailing Address - Phone:508-894-0400
Mailing Address - Fax:508-894-0617
Practice Address - Street 1:210 QUINCY AVE
Practice Address - Street 2:
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02302-2862
Practice Address - Country:US
Practice Address - Phone:508-894-0400
Practice Address - Fax:508-894-0617
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2020-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT196104207R00000X
MEMD20142207RR0500X
MA282091207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine