Healthcare Provider Details

I. General information

NPI: 1760986905
Provider Name (Legal Business Name): MATEEN COLLIS MOGHBEL MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/21/2018
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

331 OAK MANOR DR STE 102
GLEN BURNIE MD
21061-5553
US

IV. Provider business mailing address

331 OAK MANOR DR STE 102
GLEN BURNIE MD
21061-5553
US

V. Phone/Fax

Practice location:
  • Phone: 443-333-1894
  • Fax: 443-333-1894
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License NumberD0105128
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number285940
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: