Healthcare Provider Details

I. General information

NPI: 1427158146
Provider Name (Legal Business Name): MOINUDDIN HUDALLIL MUTTAKIN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2006
Last Update Date: 01/12/2022
Certification Date: 01/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

115 MILL ST
BELMONT MA
02478-1041
US

IV. Provider business mailing address

20 PARTRIDGE WAY
HOLLISTON MA
01746-2645
US

V. Phone/Fax

Practice location:
  • Phone: 617-855-2524
  • Fax:
Mailing address:
  • Phone: 508-429-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number53553
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number53553
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: