Provider Demographics
NPI:1275500902
Name:MUTHU, GERALD (MD,)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:
Last Name:MUTHU
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 1:1653 E MCMURRAY BLVD STE 132
Mailing Address - Street 2:
Mailing Address - City:CASA GRANDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85122-5934
Mailing Address - Country:US
Mailing Address - Phone:520-876-0478
Mailing Address - Fax:520-876-0484
Practice Address - Street 1:1653 E MCMURRAY BLVD STE 132
Practice Address - Street 2:
Practice Address - City:CASA GRANDE
Practice Address - State:AZ
Practice Address - Zip Code:85122-5934
Practice Address - Country:US
Practice Address - Phone:520-876-0478
Practice Address - Fax:520-876-0484
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2015-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ25612207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZH48499Medicare UPIN
AZG64280Medicare UPIN