Provider Demographics
NPI:1023018470
Name:MUSTAFA, EID B (MD)
Entity Type:Individual
Prefix:
First Name:EID
Middle Name:B
Last Name:MUSTAFA
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 1:1201 BROOK AVE
Mailing Address - Street 2:
Mailing Address - City:WICHITA FALLS
Mailing Address - State:TX
Mailing Address - Zip Code:76301-5601
Mailing Address - Country:US
Mailing Address - Phone:940-322-1122
Mailing Address - Fax:940-767-8918
Practice Address - Street 1:1201 BROOK AVE
Practice Address - Street 2:
Practice Address - City:WICHITA FALLS
Practice Address - State:TX
Practice Address - Zip Code:76301-5601
Practice Address - Country:US
Practice Address - Phone:940-322-1122
Practice Address - Fax:940-767-8918
Is Sole Proprietor?:No
Enumeration Date:2005-07-28
Last Update Date:2014-05-12
Deactivation Date:2006-03-22
Deactivation Code:
Reactivation Date:2006-04-03
Provider Licenses
StateLicense IDTaxonomies
TXG2722086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
240006708OtherRAILROAD MEDICARE PIN
TX120179005Medicaid
TX00947XMedicare PIN
8C8129Medicare PIN
B25054Medicare UPIN