Provider Demographics
NPI:1558362558
Name:AL-MUTAWA, TARIQ SUBHI (MD)
Entity Type:Individual
Prefix:
First Name:TARIQ
Middle Name:SUBHI
Last Name:AL-MUTAWA
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 1:1510 E FLOWER ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85014-5698
Mailing Address - Country:US
Mailing Address - Phone:602-530-6900
Mailing Address - Fax:
Practice Address - Street 1:1510 E FLOWER ST
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85014-5698
Practice Address - Country:US
Practice Address - Phone:602-530-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2014-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ30032207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ690778Medicaid
AZ690778Medicaid