Provider Demographics
NPI:1134101892
Name:MUMTAZ, RUSHDA (MD)
Entity Type:Individual
Prefix:DR
First Name:RUSHDA
Middle Name:
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 1:2902 E GARY WAY
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85042-7107
Mailing Address - Country:US
Mailing Address - Phone:602-309-7716
Mailing Address - Fax:
Practice Address - Street 1:1310 N 24TH ST STE 100
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008
Practice Address - Country:US
Practice Address - Phone:602-254-6101
Practice Address - Fax:602-279-1720
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-17
Last Update Date:2018-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ28980174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ550899Medicaid
AZH34879Medicare UPIN
AZ102043Medicare ID - Type Unspecified