Provider Demographics
NPI:1043302243
Name:EID B. MUSTAFA, MD PA
Entity Type:Organization
Organization Name:EID B. MUSTAFA, MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BUSINESS OFFICE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:STIVERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:940-322-1122
Mailing Address - Street 1:1201 BROOK AVENUE
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 AVENUE
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2008-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG27922082S0105X, 2086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Multi-Specialty
No2082S0105XAllopathic & Osteopathic PhysiciansPlastic SurgerySurgery of the HandGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX240006708OtherRR MEDICARE IDENTIFIER
TX171591401Medicaid
TXB25054Medicare UPIN
TX00947XMedicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER