Provider Demographics
NPI:1164423257
Name:MOHTASEB, HAMDY A (MD, FACP)
Entity Type:Individual
Prefix:DR
First Name:HAMDY
Middle Name:A
Last Name:MOHTASEB
Suffix:
Gender:M
Credentials:MD, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 HANCOCK RD STE 204
Mailing Address - Street 2:
Mailing Address - City:BULLHEAD CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:86442-5962
Mailing Address - Country:US
Mailing Address - Phone:928-219-4560
Mailing Address - Fax:928-219-4561
Practice Address - Street 1:1225 HANCOCK RD STE 204
Practice Address - Street 2:
Practice Address - City:BULLHEAD CITY
Practice Address - State:AZ
Practice Address - Zip Code:86442-5962
Practice Address - Country:US
Practice Address - Phone:928-219-4560
Practice Address - Fax:928-219-4561
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2020-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ35245207RH0003X, 207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV12007OtherMD LICENSE
NJ40903OtherAMERIGROUP
NJ6670901Medicaid
AZ35245OtherMD LICENSE
AZ6441700001OtherMEDICARE DMERC
NJ6670901Medicaid
G08323Medicare UPIN
NJMA61425OtherLISCENSE