Provider Demographics
NPI:1295751113
Name:HUSAIN, MUMTAZ (MD)
Entity type:Individual
Prefix:
First Name:MUMTAZ
Middle Name:
Last Name:HUSAIN
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:PO BOX 2346
Mailing Address - Street 2:15688 ST RT 170
Mailing Address - City:EAST LIVERPOOL
Mailing Address - State:OH
Mailing Address - Zip Code:43920
Mailing Address - Country:US
Mailing Address - Phone:330-385-4004
Mailing Address - Fax:330-385-3949
Practice Address - Street 1:15688 ST RT 170
Practice Address - Street 2:
Practice Address - City:EAST LIVERPOOL
Practice Address - State:OH
Practice Address - Zip Code:43920
Practice Address - Country:US
Practice Address - Phone:330-385-4004
Practice Address - Fax:330-385-3949
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2012-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-068803207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0188943Medicaid
G11525Medicare UPIN
OHHV0787081Medicare ID - Type Unspecified