Provider Demographics
NPI:1184684045
Name:MUSTAFA, GHULAM (MD)
Entity Type:Individual
Prefix:
First Name:GHULAM
Middle Name:
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 1:210 SOUTH MAIN STREET
Mailing Address - Street 2:
Mailing Address - City:ALBION
Mailing Address - State:NY
Mailing Address - Zip Code:14411
Mailing Address - Country:US
Mailing Address - Phone:585-589-7874
Mailing Address - Fax:585-589-2958
Practice Address - Street 1:210 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:ALBION
Practice Address - State:NY
Practice Address - Zip Code:14411
Practice Address - Country:US
Practice Address - Phone:585-589-7874
Practice Address - Fax:585-589-2958
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001051208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered208000000XAllopathic & Osteopathic PhysiciansPediatrics
Not Answered2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02069961Medicaid
NY1210914OtherINDEPENDENT HEALTH