Healthcare Provider Details

I. General information

NPI: 1972577930
Provider Name (Legal Business Name): MTANIUS A SULTANI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/15/2006
Last Update Date: 05/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

581 MEDICAL DR
CLARKSDALE MS
38614
US

IV. Provider business mailing address

PO BOX 1887
CLARKSDALE MS
38614
US

V. Phone/Fax

Practice location:
  • Phone: 662-627-7163
  • Fax: 662-627-7150
Mailing address:
  • Phone: 662-627-7163
  • Fax: 662-627-7150

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RH0003X
TaxonomyHematology & Oncology Physician
License Number15212
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: