Provider Demographics
NPI:1659902682
Name:MUSTACHIA, JOHN JAMES III
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:JAMES
Last Name:MUSTACHIA
Suffix:III
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2602 HOLLYBROOK DR
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:TX
Mailing Address - Zip Code:77586-2848
Mailing Address - Country:US
Mailing Address - Phone:218-790-4882
Mailing Address - Fax:
Practice Address - Street 1:2602 HOLLYBROOK DR
Practice Address - Street 2:
Practice Address - City:SEABROOK
Practice Address - State:TX
Practice Address - Zip Code:77586-2848
Practice Address - Country:US
Practice Address - Phone:218-790-4882
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-29
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX982740163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse