Provider Demographics
NPI:1679551550
Name:MUTIB, OMAIR K (MD)
Entity type:Individual
Prefix:
First Name:OMAIR
Middle Name:K
Last Name:MUTIB
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:WEST ROXBURY VAMC
Mailing Address - Street 2:1400 VFW PKWY,
Mailing Address - City:WESTROXBURY
Mailing Address - State:MA
Mailing Address - Zip Code:02132
Mailing Address - Country:US
Mailing Address - Phone:617-323-7700
Mailing Address - Fax:
Practice Address - Street 1:718 SMYTH RD
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NH
Practice Address - Zip Code:03104-7004
Practice Address - Country:US
Practice Address - Phone:603-624-4366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2020-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA208851207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA207PE0004XOtherVA TAXONOMY