Provider Demographics
NPI:1518924695
Name:MUMTAZ, MUBASHIR AHMED (MD)
Entity Type:Individual
Prefix:DR
First Name:MUBASHIR
Middle Name:AHMED
Last Name:MUMTAZ
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:409 S 2ND ST
Mailing Address - Street 2:SUITE 2F
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17104-1612
Mailing Address - Country:US
Mailing Address - Phone:717-231-8555
Mailing Address - Fax:717-231-8568
Practice Address - Street 1:205 S FRONT STREET
Practice Address - Street 2:4TH FL, BMA
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17104-1619
Practice Address - Country:US
Practice Address - Phone:717-231-8555
Practice Address - Fax:717-231-8568
Is Sole Proprietor?:No
Enumeration Date:2006-05-01
Last Update Date:2021-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD421279208G00000X, 208G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208G00000XAllopathic & Osteopathic PhysiciansThoracic Surgery (Cardiothoracic Vascular Surgery)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA101220727Medicaid
PA102446264Medicaid
PA087933Medicare PIN
PA1012207270Medicaid