Provider Demographics
NPI:1649240755
Name:MOSTAFAVI, MOHAMMAD R (MD)
Entity Type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:R
Last Name:MOSTAFAVI
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:3640 MAIN ST
Mailing Address - Street 2:SUITE 103
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01107-1145
Mailing Address - Country:US
Mailing Address - Phone:413-785-5321
Mailing Address - Fax:413-731-7130
Practice Address - Street 1:3640 MAIN ST
Practice Address - Street 2:SUITE 103
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01107-1145
Practice Address - Country:US
Practice Address - Phone:413-785-5321
Practice Address - Fax:413-731-7130
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2009-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MA151357208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAA21478Medicare ID - Type Unspecified
340014644Medicare PIN
MAG31103Medicare UPIN