Provider Demographics
NPI:1427158146
Name:MUTTAKIN, MOINUDDIN HUDALLIL (MD)
Entity type:Individual
Prefix:
First Name:MOINUDDIN
Middle Name:HUDALLIL
Last Name:MUTTAKIN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 PARTRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLISTON
Mailing Address - State:MA
Mailing Address - Zip Code:01746-2645
Mailing Address - Country:US
Mailing Address - Phone:508-429-3033
Mailing Address - Fax:
Practice Address - Street 1:115 MILL ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-1041
Practice Address - Country:US
Practice Address - Phone:617-855-2524
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-23
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA535532084P0805X, 2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3100073Medicaid
MAJ13043OtherBCBS
MA3100073Medicaid
E83674Medicare UPIN