Provider Demographics
NPI:1225133929
Name:SADRY, MOSTAFA SELED (MD)
Entity Type:Individual
Prefix:
First Name:MOSTAFA
Middle Name:SELED
Last Name:SADRY
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 1:2603 ELECTRIC AVE
Mailing Address - Street 2:STE 2 MOSTAFA S SADRY MD PC
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060
Mailing Address - Country:US
Mailing Address - Phone:810-985-4100
Mailing Address - Fax:810-985-8244
Practice Address - Street 1:2603 ELECTRIC AVE
Practice Address - Street 2:STE 2
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060
Practice Address - Country:US
Practice Address - Phone:810-985-4100
Practice Address - Fax:810-985-8244
Is Sole Proprietor?:No
Enumeration Date:2006-09-14
Last Update Date:2017-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMS440762084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
2118850Medicare ID - Type Unspecified
B46279Medicare UPIN