Provider Demographics
NPI:1780653139
Name:SHAYEGAN, MUSTAPHA (MD)
Entity Type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:
Last Name:SHAYEGAN
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8118 BUSTLETON AVE
Mailing Address - Street 2:
Mailing Address - City:PHILA
Mailing Address - State:PA
Mailing Address - Zip Code:19152-2803
Mailing Address - Country:US
Mailing Address - Phone:215-342-8118
Mailing Address - Fax:215-725-4999
Practice Address - Street 1:8118 BUSTLETON AVE
Practice Address - Street 2:
Practice Address - City:PHILA
Practice Address - State:PA
Practice Address - Zip Code:19152-2803
Practice Address - Country:US
Practice Address - Phone:215-342-8118
Practice Address - Fax:215-725-4999
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD036243L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAC31238Medicare UPIN