MEDICARE: DR. GHULAM MUJTABA MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0800X	Psychiatry Physician	125.077354	IL

General Provider Information

NPI Number	:	1881213593
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GHULAM MUJTABA MD

Provider Business Mailing Address
First Line	:	109 W 27TH ST RM 5S
Second Line	:
City	:	NEW YORK
State	:	NY
Zip	:	10001-6208
Country	:	US
Telephone Number	:	833-351-8255
Fax Number	:

Provider Business Practice Location Address
First Line	:	3223 S LOOP 289
Second Line	:	SUITE 600 (PRIVATE OFFICE 630)
City	:	LUBBOCK
State	:	TX
Zip	:	79423
Country	:	US
Telephone Number	:	833-351-8255
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/13/2020
Last Update Date	:	04/23/2026

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