Provider Demographics
NPI:1417397589
Name:MUSHTAQ, KAMRAN (MD)
Entity Type:Individual
Prefix:
First Name:KAMRAN
Middle Name:
Last Name:MUSHTAQ
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:PO BOX 236
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:IN
Mailing Address - Zip Code:46761-0236
Mailing Address - Country:US
Mailing Address - Phone:260-463-2133
Mailing Address - Fax:260-463-3775
Practice Address - Street 1:2500 N DETROIT ST
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:IN
Practice Address - Zip Code:46761
Practice Address - Country:US
Practice Address - Phone:260-463-2133
Practice Address - Fax:260-463-3775
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2022-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103687207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine