Provider Demographics
NPI:1174722805
Name:QAIYUM MUJTABA, M.D., P.C.
Entity type:Organization
Organization Name:QAIYUM MUJTABA, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:QAIYUM
Authorized Official - Middle Name:
Authorized Official - Last Name:MUJTABA
Authorized Official - Suffix:
Authorized Official - Credentials:M D
Authorized Official - Phone:203-931-7710
Mailing Address - Street 1:750 SAVIN AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06516-4314
Mailing Address - Country:US
Mailing Address - Phone:203-931-7710
Mailing Address - Fax:
Practice Address - Street 1:750 SAVIN AVE
Practice Address - Street 2:
Practice Address - City:WEST HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06516-4314
Practice Address - Country:US
Practice Address - Phone:203-931-7710
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-12
Last Update Date:2007-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT16546207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CTC02188Medicare PIN