Provider Demographics
NPI:1497841860
Name:MUSTAFA, MARIANNE A (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIANNE
Middle Name:A
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:100 SARATOGA VILLAGE BLVD
Mailing Address - Street 2:SUITE 34
Mailing Address - City:MALTA
Mailing Address - State:NY
Mailing Address - Zip Code:12020-3737
Mailing Address - Country:US
Mailing Address - Phone:518-899-9099
Mailing Address - Fax:518-899-9098
Practice Address - Street 1:100 SARATOGA VILLAGE BLVD
Practice Address - Street 2:SUITE 34
Practice Address - City:MALTA
Practice Address - State:NY
Practice Address - Zip Code:12020-3737
Practice Address - Country:US
Practice Address - Phone:518-899-9099
Practice Address - Fax:518-899-9098
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-05
Last Update Date:2012-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY226100207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY002370267Medicaid
NYDD3195Medicare ID - Type Unspecified
NY002370267Medicaid