Healthcare Provider Details

I. General information

NPI: 1154150613
Provider Name (Legal Business Name): MITZ SYED QUTB OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/31/2024
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 WEST ST
WORCESTER MA
01609-2306
US

IV. Provider business mailing address

21 WEST ST
WORCESTER MA
01609-2306
US

V. Phone/Fax

Practice location:
  • Phone: 508-340-6569
  • Fax:
Mailing address:
  • Phone: 508-340-6569
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number5738
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: