Provider Demographics
NPI:1790856953
Name:CASSIM, MUTHALIB M (MD)
Entity Type:Individual
Prefix:
First Name:MUTHALIB
Middle Name:M
Last Name:CASSIM
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 1:900 11TH ST SE
Mailing Address - Street 2:
Mailing Address - City:BANDON
Mailing Address - State:OR
Mailing Address - Zip Code:97411-9114
Mailing Address - Country:US
Mailing Address - Phone:541-347-2426
Mailing Address - Fax:541-347-3923
Practice Address - Street 1:913 11TH ST SE
Practice Address - Street 2:
Practice Address - City:BANDON
Practice Address - State:OR
Practice Address - Zip Code:97411-9168
Practice Address - Country:US
Practice Address - Phone:541-347-2426
Practice Address - Fax:541-347-3923
Is Sole Proprietor?:No
Enumeration Date:2006-11-10
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD11038208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR057083Medicaid
C92372Medicare UPIN
OR130630Medicare ID - Type Unspecified