Provider Demographics
NPI:1265523302
Name:GEORGE, MUMTAZ (MD)
Entity type:Individual
Prefix:DR
First Name:MUMTAZ
Middle Name:
Last Name:GEORGE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5130 COOLIDGE HWY
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-1001
Mailing Address - Country:US
Mailing Address - Phone:248-288-9500
Mailing Address - Fax:248-288-0044
Practice Address - Street 1:5130 COOLIDGE HWY
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-1001
Practice Address - Country:US
Practice Address - Phone:248-288-9500
Practice Address - Fax:248-288-0044
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2010-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301038490207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIB48658Medicare UPIN