Provider Demographics
NPI:1679068506
Name:MUTTALIB, REHAN (MD)
Entity Type:Individual
Prefix:
First Name:REHAN
Middle Name:
Last Name:MUTTALIB
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 1:23639 HAWTHORNE BLVD STE 102
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90505-5985
Mailing Address - Country:US
Mailing Address - Phone:310-373-9980
Mailing Address - Fax:
Practice Address - Street 1:23639 HAWTHORNE BLVD STE 102
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90505-5985
Practice Address - Country:US
Practice Address - Phone:310-373-9980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-06-23
Last Update Date:2022-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCLL52609207Q00000X
CAA174176207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA174176OtherTHE MEDICAL BOARD OF CALIFORNIA