Provider Demographics
NPI:1255993309
Name:HUSSAIN, MUJTABA (MBBS)
Entity type:Individual
Prefix:DR
First Name:MUJTABA
Middle Name:
Last Name:HUSSAIN
Suffix:
Gender:M
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:111 N WASHINGTON AVE FL 1
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1841
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:101 MADISON ST STE 300
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:IL
Practice Address - Zip Code:60302-4210
Practice Address - Country:US
Practice Address - Phone:708-486-2700
Practice Address - Fax:708-486-2702
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-28
Last Update Date:2023-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL161327207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine