Provider Demographics
NPI:1043896731
Name:QUTAB, GHULAM (MD)
Entity Type:Individual
Prefix:
First Name:GHULAM
Middle Name:
Last Name:QUTAB
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 1:1405 AMSTERDAM AVE APT 3A
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10027-7465
Mailing Address - Country:US
Mailing Address - Phone:929-385-2375
Mailing Address - Fax:
Practice Address - Street 1:48 CEDAR ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11221-3253
Practice Address - Country:US
Practice Address - Phone:718-455-6200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-22
Last Update Date:2021-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY100952-05208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice