Provider Demographics
NPI:1316060502
Name:MUMTAZ, SANOBER HUMAYUM (MD)
Entity type:Individual
Prefix:
First Name:SANOBER
Middle Name:HUMAYUM
Last Name:MUMTAZ
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 1:3001 BELMEAD
Mailing Address - Street 2:
Mailing Address - City:TYLER
Mailing Address - State:TX
Mailing Address - Zip Code:75701
Mailing Address - Country:US
Mailing Address - Phone:903-530-7486
Mailing Address - Fax:903-595-6547
Practice Address - Street 1:820 E FRONT STREET
Practice Address - Street 2:WILLOW WELLNESS CENTER PA
Practice Address - City:TYLER
Practice Address - State:TX
Practice Address - Zip Code:75702
Practice Address - Country:US
Practice Address - Phone:903-596-0602
Practice Address - Fax:903-596-0620
Is Sole Proprietor?:No
Enumeration Date:2007-04-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXE4553207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXV25025Medicare UPIN
TX00535265Medicare ID - Type Unspecified