Healthcare Provider Details

I. General information

NPI: 1639755218
Provider Name (Legal Business Name): MUDASSIR MUMTAZ MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2021
Last Update Date: 08/16/2026
Certification Date: 08/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

ONE GUSTAVE L. LEVY PL RADIOLOGY, MC LEVEL
NEW YORK NY
10029
US

IV. Provider business mailing address

75 N COUNTRY RD
PORT JEFFERSON NY
11777-2190
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6500
  • Fax:
Mailing address:
  • Phone: 631-686-2549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0700X
TaxonomyNeuroradiology Physician
License Number334820
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: