Basic Information
| Provider Information | |||||||||
| NPI: | 1790917052 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ALTAF | ||||||||
| FirstName: | MISBAH | ||||||||
| MiddleName: | W. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3620 N 3RD ST | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850122020 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 6026827455 | ||||||||
| Practice Location | |||||||||
| Address1: | 2204 S DOBSON RD STE 201 | ||||||||
| Address2: | |||||||||
| City: | MESA | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 852026457 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6022307373 | ||||||||
| FaxNumber: | 4806298574 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2009 | ||||||||
| LastUpdateDate: | 12/06/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | PT12461 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | RL11228 | ND | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 52163 | AZ | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 210891 | 05 | AZ | MEDICAID | 12083 | 05 | ND | MEDICAID |