Provider Demographics
NPI:1508801986
Name:MUSTAPHA, FADI M (MD)
Entity Type:Individual
Prefix:DR
First Name:FADI
Middle Name:M
Last Name:MUSTAPHA
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 1:215 E 1ST ST
Mailing Address - Street 2:
Mailing Address - City:DIXON
Mailing Address - State:IL
Mailing Address - Zip Code:61021-3175
Mailing Address - Country:US
Mailing Address - Phone:815-285-5843
Mailing Address - Fax:815-285-5846
Practice Address - Street 1:215 E 1ST ST
Practice Address - Street 2:
Practice Address - City:DIXON
Practice Address - State:IL
Practice Address - Zip Code:61021
Practice Address - Country:US
Practice Address - Phone:815-285-5843
Practice Address - Fax:815-285-5846
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2018-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-115681207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILK28334OtherMEDICARE
IL036-115681OtherILLINOIS MEDICAL LICENSE