Provider Demographics
NPI:1821319591
Name:MUSTAFA, FAHAD KARIM (MD)
Entity Type:Individual
Prefix:
First Name:FAHAD
Middle Name:KARIM
Last Name:MUSTAFA
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 1:350 SURRYSE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-3217
Mailing Address - Country:US
Mailing Address - Phone:847-438-2144
Mailing Address - Fax:847-438-4654
Practice Address - Street 1:350 SURRYSE RD
Practice Address - Street 2:
Practice Address - City:LAKE ZURICH
Practice Address - State:IL
Practice Address - Zip Code:60047-3217
Practice Address - Country:US
Practice Address - Phone:847-438-2144
Practice Address - Fax:847-438-4654
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-17
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036131735207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine