Basic Information
| Provider Information | |||||||||
| NPI: | 1861438822 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUTTERPERL | ||||||||
| FirstName: | ROBERT | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2370 CORPORATE CIR STE 300 | ||||||||
| Address2: | |||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890747760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7029103950 | ||||||||
| FaxNumber: | 7027866650 | ||||||||
| Practice Location | |||||||||
| Address1: | 6296 E GRANT RD STE 140 | ||||||||
| Address2: | |||||||||
| City: | TUCSON | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 857125876 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5202983321 | ||||||||
| FaxNumber: | 8889782518 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2006 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 3369 | AZ | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 792417 | 05 | AZ | MEDICAID | AZ0765360 | 01 | AZ | BCBSAZ | OTHER | 3369 | 01 | AZ | AZ STATE MEDICAL LICENSE | OTHER | 410348 | 05 | AZ | MEDICAID |