Provider Demographics
NPI:1295826675
Name:MUSTARD, MICHAEL R (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:R
Last Name:MUSTARD
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 1:1005 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-2834
Mailing Address - Country:US
Mailing Address - Phone:217-223-8400
Mailing Address - Fax:217-277-3960
Practice Address - Street 1:1005 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:QUINCY
Practice Address - State:IL
Practice Address - Zip Code:62301-2834
Practice Address - Country:US
Practice Address - Phone:217-223-8400
Practice Address - Fax:217-214-5837
Is Sole Proprietor?:No
Enumeration Date:2006-09-28
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2009-00236207Q00000X
IL036115033207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036115033Medicaid
NC5911855Medicaid
ILCA2264Medicare ID - Type UnspecifiedRR GROUP #
NC2073732MMedicare PIN
NC2073732PMedicare PIN
NC2073732FMedicare PIN
NC2073732EMedicare PIN
ILP00336272Medicare ID - Type UnspecifiedRR INDIVIDUAL #
NC2073732AMedicare PIN
NC5911855Medicaid
IL833120Medicare ID - Type UnspecifiedGROUP #
IL036115033Medicaid
NC2073732BMedicare PIN
NC2073732Medicare PIN
NC2073732NMedicare PIN
NC2073732CMedicare PIN
NC2073732KMedicare PIN
NC2073732HMedicare PIN
NC2073732JMedicare PIN
NC2073732DMedicare PIN