1043241797 NPI number — FAYEZA F MULLAMITHAWALA P.T.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1043241797 NPI number — FAYEZA F MULLAMITHAWALA P.T.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MULLAMITHAWALA
Provider First Name:
FAYEZA
Provider Middle Name:
F
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
P.T.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1043241797
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
587 KINGSTON RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BELMONT
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94002-2319
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
650-868-8286
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1740 MARCO POLO WAY
Provider Second Line Business Practice Location Address:
SUITE 3
Provider Business Practice Location Address City Name:
BURLINGAME
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94010-4522
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
650-552-9355
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PT28154 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PT0281540 . This is a "BLUE SHIELD ID NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".
  • Identifier: PT28154 . This is a "PT LICENSE NUMBER" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




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