Provider Demographics
NPI:1891249793
Name:MUJTABA, TARANNUM (MD)
Entity Type:Individual
Prefix:DR
First Name:TARANNUM
Middle Name:
Last Name:MUJTABA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5841 S. MARYLAND AVE.
Mailing Address - Street 2:RM.Q219, M/C2026
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60637
Mailing Address - Country:US
Mailing Address - Phone:773-834-9980
Mailing Address - Fax:
Practice Address - Street 1:1760 S STATE ROAD 7
Practice Address - Street 2:APT. 202
Practice Address - City:NORTH LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33068-4659
Practice Address - Country:US
Practice Address - Phone:305-505-8090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-09
Last Update Date:2021-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IL036.1525722085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program