Provider Demographics
NPI:1609437219
Name:MUSTAFA, JALLA TARAK (DO)
Entity Type:Individual
Prefix:DR
First Name:JALLA
Middle Name:TARAK
Last Name:MUSTAFA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4106 EMERICK CT
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:PA
Mailing Address - Zip Code:16506-6410
Mailing Address - Country:US
Mailing Address - Phone:858-213-3620
Mailing Address - Fax:
Practice Address - Street 1:5515 PEACH ST
Practice Address - Street 2:
Practice Address - City:ERIE
Practice Address - State:PA
Practice Address - Zip Code:16509-2695
Practice Address - Country:US
Practice Address - Phone:814-868-8217
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-25
Last Update Date:2022-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT019576207R00000X
AZ009516207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine