Basic Information
| Provider Information | |||||||||
| NPI: | 1861780090 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MUKHTAR | ||||||||
| FirstName: | JALAL | ||||||||
| MiddleName: | |||||||||
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| Credential: | M.D | ||||||||
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| Mailing Information | |||||||||
| Address1: | 210 QUINCY AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023022862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940617 | ||||||||
| Practice Location | |||||||||
| Address1: | 210 QUINCY AVE | ||||||||
| Address2: | |||||||||
| City: | BROCKTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 023022862 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5088940400 | ||||||||
| FaxNumber: | 5088940617 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2011 | ||||||||
| LastUpdateDate: | 06/01/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/01/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MT196104 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RR0500X | MD20142 | ME | N | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology | 207RR0500X | 282091 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Rheumatology |
No ID Information.