Provider Demographics
NPI:1417973678
Name:MUMTAZ, GHAZALA T (MD)
Entity Type:Individual
Prefix:
First Name:GHAZALA
Middle Name:T
Last Name:MUMTAZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:724 W VINE STREET
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4931
Mailing Address - Country:US
Mailing Address - Phone:407-944-4450
Mailing Address - Fax:407-944-1858
Practice Address - Street 1:724 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4161
Practice Address - Country:US
Practice Address - Phone:407-944-4450
Practice Address - Fax:407-944-1858
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME93344207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLI43998Medicare UPIN