Healthcare Provider Details

I. General information

NPI: 1316060502
Provider Name (Legal Business Name): SANOBER HUMAYUM MUMTAZ MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 E FRONT STREET WILLOW WELLNESS CENTER PA
TYLER TX
75702
US

IV. Provider business mailing address

3001 BELMEAD
TYLER TX
75701
US

V. Phone/Fax

Practice location:
  • Phone: 903-596-0602
  • Fax: 903-596-0620
Mailing address:
  • Phone: 903-530-7486
  • Fax: 903-595-6547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberE4553
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: