Provider Demographics
NPI:1275625840
Name:MUMTAZ, MUHAMMAD ALI (MD)
Entity Type:Individual
Prefix:
First Name:MUHAMMAD
Middle Name:ALI
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 1:10140 CENTURION PKWY N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32256-0532
Mailing Address - Country:US
Mailing Address - Phone:904-697-4100
Mailing Address - Fax:904-391-5075
Practice Address - Street 1:807 CHILDRENS WAY
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32207-8426
Practice Address - Country:US
Practice Address - Phone:904-687-3927
Practice Address - Fax:904-687-3927
Is Sole Proprietor?:No
Enumeration Date:2006-09-29
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101245965208G00000X
TXP8165208G00000X
OH35078178M208G00000X
FLME156588208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2182490Medicaid
VA1275625840Medicaid
NC5912709Medicaid
NC5912709Medicaid
VAC06141Medicare PIN