Provider Demographics
NPI:1912198573
Name:TABBAA, MUTAZ A (MD)
Entity Type:Individual
Prefix:DR
First Name:MUTAZ
Middle Name:A
Last Name:TABBAA
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 1:2559 HUNTCLIFF LN
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4902
Mailing Address - Country:US
Mailing Address - Phone:850-763-0333
Mailing Address - Fax:850-763-1477
Practice Address - Street 1:2559 HUNTCLIFF LN
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4902
Practice Address - Country:US
Practice Address - Phone:850-763-0333
Practice Address - Fax:850-763-1477
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-07
Last Update Date:2007-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME48669174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLD50170OtherUPIN
FL01496OtherBCBS PROVIDER NUMBER
FL044278000Medicaid
FL130018687OtherRAILROAD MEDICARE NUMBER
FLD50170OtherUPIN