Provider Demographics
NPI:1376785626
Name:MUSTAFA SIDALI DO PC
Entity Type:Organization
Organization Name:MUSTAFA SIDALI DO PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MUSTAFA
Authorized Official - Middle Name:M
Authorized Official - Last Name:SIDALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:973-759-4411
Mailing Address - Street 1:380 UNION AVE
Mailing Address - Street 2:
Mailing Address - City:BELLEVILLE
Mailing Address - State:NJ
Mailing Address - Zip Code:07109-2122
Mailing Address - Country:US
Mailing Address - Phone:973-759-4411
Mailing Address - Fax:
Practice Address - Street 1:380 UNION AVE
Practice Address - Street 2:
Practice Address - City:BELLEVILLE
Practice Address - State:NJ
Practice Address - Zip Code:07109-2122
Practice Address - Country:US
Practice Address - Phone:973-759-4411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-01
Last Update Date:2013-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJG59826Medicare UPIN