Provider Demographics
NPI:1619603925
Name:GEORGE MATHEW MUKALI, FNU MATHEW (MD)
Entity Type:Individual
Prefix:
First Name:FNU
Middle Name:MATHEW
Last Name:GEORGE MATHEW MUKALI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:GEORGE
Other - Middle Name:MATHEW
Other - Last Name:MUKALIL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1000 HOUGHTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-5303
Mailing Address - Country:US
Mailing Address - Phone:989-746-7500
Mailing Address - Fax:
Practice Address - Street 1:1000 HOUGHTON AVE
Practice Address - Street 2:
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5303
Practice Address - Country:US
Practice Address - Phone:989-746-7500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-28
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351049072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine