Provider Demographics
NPI:1316438583
Name:BABA MOHAMMED KHAJA, MUBARIZUDDIN
Entity type:Individual
Prefix:
First Name:MUBARIZUDDIN
Middle Name:
Last Name:BABA MOHAMMED KHAJA
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 1:1 WHEELER PL
Mailing Address - Street 2:APT 1
Mailing Address - City:LIBERTY
Mailing Address - State:NY
Mailing Address - Zip Code:12754-1725
Mailing Address - Country:US
Mailing Address - Phone:872-806-6833
Mailing Address - Fax:845-791-8073
Practice Address - Street 1:6319 N LEAVITT ST APT 18F
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60659-2113
Practice Address - Country:US
Practice Address - Phone:872-806-6833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY042682225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty