Provider Demographics
NPI:1053346148
Name:MUMTAZ, SYED T (MDPA)
Entity type:Individual
Prefix:
First Name:SYED
Middle Name:T
Last Name:MUMTAZ
Suffix:
Gender:M
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:724 W VINE ST
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-4161
Mailing Address - Country:US
Mailing Address - Phone:407-944-4450
Mailing Address - Fax:407-944-1858
Practice Address - Street 1:724 W VINE ST
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-4161
Practice Address - Country:US
Practice Address - Phone:407-944-4450
Practice Address - Fax:407-944-1858
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME70936174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG-32489Medicare UPIN