Provider Demographics
NPI:1437112083
Name:BOURARA, MUSTAPHA (MD)
Entity Type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:
Last Name:BOURARA
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 1:2427 STEINWAY ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11103-3654
Mailing Address - Country:US
Mailing Address - Phone:718-721-2787
Mailing Address - Fax:718-721-5995
Practice Address - Street 1:2427 STEINWAY ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11103-3654
Practice Address - Country:US
Practice Address - Phone:718-721-2787
Practice Address - Fax:718-721-5995
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-06
Last Update Date:2010-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY234094207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02639081Medicaid
NY0105UPMedicare ID - Type Unspecified
NY02639081Medicaid
I26356Medicare UPIN