Healthcare Provider Details

I. General information

NPI: 1528465655
Provider Name (Legal Business Name): ABIJAH MUTHYALA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2014
Last Update Date: 10/18/2023
Certification Date: 10/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BEAM AVE
MAPLEWOOD MN
55109
US

IV. Provider business mailing address

8901 MISSION RD
LEAWOOD KS
66206-1709
US

V. Phone/Fax

Practice location:
  • Phone: 651-326-7200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2018012787
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number63818
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number63818
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: