Provider Demographics
NPI:1093956765
Name:MUSTAPHA, ADEOLA (MD)
Entity Type:Individual
Prefix:
First Name:ADEOLA
Middle Name:
Last Name:MUSTAPHA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:520 S. SEVENTH ST. VINCENNES
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591
Mailing Address - Country:US
Mailing Address - Phone:812-885-3228
Mailing Address - Fax:
Practice Address - Street 1:520 S 7TH ST
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1038
Practice Address - Country:US
Practice Address - Phone:812-882-5220
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-03-10
Last Update Date:2020-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX010765251E00000X, 3747P1801X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No251E00000XAgenciesHome Health
No3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX001018158Medicaid