Provider Demographics
NPI:1073768156
Name:AHMED, MUSTAFA HASSAN
Entity Type:Individual
Prefix:MR
First Name:MUSTAFA
Middle Name:HASSAN
Last Name:AHMED
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 1:2910 PILLSBURY AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55408-2297
Mailing Address - Country:US
Mailing Address - Phone:952-220-9158
Mailing Address - Fax:612-824-4487
Practice Address - Street 1:2910 PILLSBURY AVE S
Practice Address - Street 2:131
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55408-2297
Practice Address - Country:US
Practice Address - Phone:952-220-9158
Practice Address - Fax:763-412-8913
Is Sole Proprietor?:No
Enumeration Date:2008-11-17
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA143630100Medicaid