Provider Demographics
NPI:1104891837
Name:MUTINGA, NZISA L (MD)
Entity type:Individual
Prefix:DR
First Name:NZISA
Middle Name:L
Last Name:MUTINGA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:121 PARK CENTRAL DR
Mailing Address - Street 2:200
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6469
Mailing Address - Country:US
Mailing Address - Phone:803-252-9907
Mailing Address - Fax:803-252-9906
Practice Address - Street 1:121 PARK CENTRAL DR
Practice Address - Street 2:200
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6469
Practice Address - Country:US
Practice Address - Phone:803-252-9907
Practice Address - Fax:803-252-9906
Is Sole Proprietor?:No
Enumeration Date:2006-02-17
Last Update Date:2017-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27589207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC275892Medicaid
SC275892Medicaid
SCI28391Medicare UPIN
SCAA08322040Medicare PIN