Provider Demographics
NPI:1609801737
Name:MUSTOE, THOMAS A (MD, FACS)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:A
Last Name:MUSTOE
Suffix:
Gender:M
Credentials:MD, FACS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:737 N MICHIGAN AVE
Mailing Address - Street 2:SUITE 1500
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60611-2615
Mailing Address - Country:US
Mailing Address - Phone:312-788-2560
Mailing Address - Fax:312-788-2563
Practice Address - Street 1:737 N MICHIGAN AVE
Practice Address - Street 2:SUITE 1500
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60611-2615
Practice Address - Country:US
Practice Address - Phone:312-788-2560
Practice Address - Fax:312-788-2563
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0360821622086S0122X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
A12814Medicare UPIN
IL950070Medicare PIN