Healthcare Provider Details

I. General information

NPI: 1760451827
Provider Name (Legal Business Name): MUTAHAR AHMED MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2006
Last Update Date: 03/04/2022
Certification Date: 03/04/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 W SPRING VALLEY AVE SUITE 101
MAYWOOD NJ
07607-1445
US

IV. Provider business mailing address

1 DIAMOND HILL RD STE 101
BERKELEY HEIGHTS NJ
07922-2104
US

V. Phone/Fax

Practice location:
  • Phone: 201-487-8866
  • Fax: 201-487-2610
Mailing address:
  • Phone: 908-273-4300
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number25MA07065900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: