Healthcare Provider Details

I. General information

NPI: 1124054721
Provider Name (Legal Business Name): AZHAR MUTTALIB M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/24/2006
Last Update Date: 10/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23639 HAWTHORNE BLVD SUITE 102
TORRANCE CA
90505-5930
US

IV. Provider business mailing address

23639 HAWTHORNE BLVD SUITE 102
TORRANCE CA
90505-5930
US

V. Phone/Fax

Practice location:
  • Phone: 310-373-9980
  • Fax: 310-373-5556
Mailing address:
  • Phone: 310-373-9980
  • Fax: 310-373-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE24196
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: