Provider Demographics
NPI:1639267651
Name:MUSTAFA, MAHMOUD AHMAD (MD, FAAP)
Entity Type:Individual
Prefix:DR
First Name:MAHMOUD
Middle Name:AHMAD
Last Name:MUSTAFA
Suffix:
Gender:M
Credentials:MD, FAAP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-3109
Mailing Address - Country:US
Mailing Address - Phone:301-797-4060
Mailing Address - Fax:301-797-4197
Practice Address - Street 1:1409 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-3109
Practice Address - Country:US
Practice Address - Phone:301-797-4060
Practice Address - Fax:301-797-4197
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-11
Last Update Date:2012-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0061762208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD406134900Medicaid