Provider Demographics
NPI:1568155497
Name:MUKTAR, FAMI HALEWI
Entity Type:Individual
Prefix:
First Name:FAMI
Middle Name:HALEWI
Last Name:MUKTAR
Suffix:
Gender:M
Credentials:
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 200912
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80220-0912
Mailing Address - Country:US
Mailing Address - Phone:720-207-8796
Mailing Address - Fax:
Practice Address - Street 1:102 S TEJON ST STE 1100
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80903-2253
Practice Address - Country:US
Practice Address - Phone:720-207-8796
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-26
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO20231573071343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)