Healthcare Provider Details

I. General information

NPI: 1750961124
Provider Name (Legal Business Name): MUMTAZ ASHRAF MUNSHI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/10/2021
Last Update Date: 09/17/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11130 N TATUM BLVD STE 100
PHOENIX AZ
85028-1630
US

IV. Provider business mailing address

11130 N TATUM BLVD STE 100
PHOENIX AZ
85028-1630
US

V. Phone/Fax

Practice location:
  • Phone: 602-737-1361
  • Fax: 602-494-7103
Mailing address:
  • Phone: 602-737-1361
  • Fax: 602-494-7103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number80869
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: