Provider Demographics
NPI:1871992875
Name:MEHMOOD, GHULAM MUJTABA (PA)
Entity type:Individual
Prefix:
First Name:GHULAM
Middle Name:MUJTABA
Last Name:MEHMOOD
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:161 ZABRISKIE ST
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-4221
Mailing Address - Country:US
Mailing Address - Phone:973-922-0444
Mailing Address - Fax:
Practice Address - Street 1:8002 KEW GARDENS RD
Practice Address - Street 2:
Practice Address - City:KEW GARDENS
Practice Address - State:NY
Practice Address - Zip Code:11415-3600
Practice Address - Country:US
Practice Address - Phone:973-922-0444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-15
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY017710363A00000X, 363AM0700X, 363AS0400X
NJ25MP00345000363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Multi-Specialty