Healthcare Provider Details

I. General information

NPI: 1619497823
Provider Name (Legal Business Name): MOHAMMAD IMTIAZ MUBBASHAR MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 05/03/2023
Certification Date: 05/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

269 MEDICAL PARK BLVD
PETERSBURG VA
23805-9337
US

IV. Provider business mailing address

269 MEDICAL PARK BLVD
PETERSBURG VA
23805-9337
US

V. Phone/Fax

Practice location:
  • Phone: 804-861-0700
  • Fax:
Mailing address:
  • Phone: 804-861-0700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number2021-02312
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2021-02312
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: