Healthcare Provider Details

I. General information

NPI: 1568111607
Provider Name (Legal Business Name): IMELDA MAHMUTAJ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/23/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

IV. Provider business mailing address

100 HOSPITAL AVE
DU BOIS PA
15801-1440
US

V. Phone/Fax

Practice location:
  • Phone: 814-375-6560
  • Fax: 814-375-9320
Mailing address:
  • Phone: 814-375-6560
  • Fax: 814-375-9320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD485383
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: