Provider Demographics
NPI:1063143394
Name:MUTABAZI, DELICK
Entity type:Individual
Prefix:
First Name:DELICK
Middle Name:
Last Name:MUTABAZI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9159 W GLENROSA AVE
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85037-0812
Mailing Address - Country:US
Mailing Address - Phone:240-491-6773
Mailing Address - Fax:
Practice Address - Street 1:9159 W GLENROSA AVE
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85037-0812
Practice Address - Country:US
Practice Address - Phone:240-491-6773
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver