Provider Demographics
NPI:1639585177
Name:MUSTAFA, ISIN
Entity Type:Individual
Prefix:
First Name:ISIN
Middle Name:
Last Name:MUSTAFA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6200 PLEASANT AVE STE 3
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:OH
Mailing Address - Zip Code:45014-4671
Mailing Address - Country:US
Mailing Address - Phone:513-829-9333
Mailing Address - Fax:513-858-7827
Practice Address - Street 1:1275 OLENTANGY RIVER RD STE 10
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43212
Practice Address - Country:US
Practice Address - Phone:614-291-5555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-04
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH36003815213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist