Provider Demographics
NPI:1265472054
Name:MUSTIFUL, TASHAWN L (MD)
Entity Type:Individual
Prefix:
First Name:TASHAWN
Middle Name:L
Last Name:MUSTIFUL
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:PO BOX 1291
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-1291
Mailing Address - Country:US
Mailing Address - Phone:225-654-0522
Mailing Address - Fax:
Practice Address - Street 1:52579 HIGHWAY 51 S
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:LA
Practice Address - Zip Code:70443-2231
Practice Address - Country:US
Practice Address - Phone:225-654-0522
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA024954207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine