Provider Demographics
NPI:1376703553
Name:MUSTHAFA, RUSSELL (MD)
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
Last Name:MUSTHAFA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:RUSSELL
Other - Middle Name:
Other - Last Name:MUSTHAFA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:701 E MARSHALL ST
Mailing Address - Street 2:WEST CHESTER
Mailing Address - City:WEST CHESTER
Mailing Address - State:PA
Mailing Address - Zip Code:19380-4412
Mailing Address - Country:US
Mailing Address - Phone:610-431-5000
Mailing Address - Fax:
Practice Address - Street 1:701 E MARSHALL ST
Practice Address - Street 2:WEST CHESTER
Practice Address - City:WEST CHESTER
Practice Address - State:PA
Practice Address - Zip Code:19380-4412
Practice Address - Country:US
Practice Address - Phone:610-431-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2014-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD437488207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine