Provider Demographics
NPI:1164032447
Name:DOUGLAS, MUSTAFA FAISAL MUSTAFA (MD)
Entity Type:Individual
Prefix:
First Name:MUSTAFA
Middle Name:FAISAL MUSTAFA
Last Name:DOUGLAS
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 1:289 S HIGHWAY 92 APT 1201
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-3679
Mailing Address - Country:US
Mailing Address - Phone:312-978-0764
Mailing Address - Fax:
Practice Address - Street 1:5700 E HIGHWAY 90
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-9110
Practice Address - Country:US
Practice Address - Phone:520-263-3190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZR78390207R00000X
CAA185288208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine