Provider Demographics
NPI:1619011392
Name:AZHAR MUTTALIB MD A PROFESSIONAL CORPORATION
Entity Type:Organization
Organization Name:AZHAR MUTTALIB MD A PROFESSIONAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:AZHAR
Authorized Official - Middle Name:
Authorized Official - Last Name:MUTTALIB
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-373-9980
Mailing Address - Street 1:23639 HAWTHORNE BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5930
Mailing Address - Country:US
Mailing Address - Phone:310-373-9980
Mailing Address - Fax:310-373-5556
Practice Address - Street 1:23639 HAWTHORNE BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5930
Practice Address - Country:US
Practice Address - Phone:310-373-9980
Practice Address - Fax:310-373-5556
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2015-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2591934Medicaid
CAA45240Medicare ID - Type Unspecified
CA2591934Medicaid