Provider Demographics
NPI:1093979437
Name:MUMTAZ, KHURRAM (MD)
Entity Type:Individual
Prefix:DR
First Name:KHURRAM
Middle Name:
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 1:43576 WASHINGTON ST STE 100
Mailing Address - Street 2:
Mailing Address - City:LA QUINTA
Mailing Address - State:CA
Mailing Address - Zip Code:92253-8566
Mailing Address - Country:US
Mailing Address - Phone:760-360-4433
Mailing Address - Fax:442-300-2356
Practice Address - Street 1:43576 WASHINGTON ST STE 100
Practice Address - Street 2:
Practice Address - City:LA QUINTA
Practice Address - State:CA
Practice Address - Zip Code:92253
Practice Address - Country:US
Practice Address - Phone:610-931-6873
Practice Address - Fax:855-335-1478
Is Sole Proprietor?:No
Enumeration Date:2008-07-15
Last Update Date:2019-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC153915207RN0300X, 207RN0300X
NY003595207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00354398Medicaid
NYJ400068071Medicare PIN