Provider Demographics
NPI:1609823293
Name:MUTINGA, MUTHOKA L (MD)
Entity Type:Individual
Prefix:
First Name:MUTHOKA
Middle Name:L
Last Name:MUTINGA
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 1:1153 CENTRE ST
Mailing Address - Street 2:SUITE 45
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02130-3446
Mailing Address - Country:US
Mailing Address - Phone:617-522-9996
Mailing Address - Fax:
Practice Address - Street 1:1153 CENTRE ST
Practice Address - Street 2:SUITE 45
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02130-3446
Practice Address - Country:US
Practice Address - Phone:617-522-9996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA153759207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA32286Medicare PIN