Provider Demographics
NPI:1851635122
Name:IDRIS, MUSTAFA MUHAMMAD (DC)
Entity Type:Individual
Prefix:DR
First Name:MUSTAFA
Middle Name:MUHAMMAD
Last Name:IDRIS
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18525 NE 58TH CT
Mailing Address - Street 2:APT N2105
Mailing Address - City:REDMOND
Mailing Address - State:WA
Mailing Address - Zip Code:98052-6708
Mailing Address - Country:US
Mailing Address - Phone:425-638-3092
Mailing Address - Fax:
Practice Address - Street 1:3925 159TH AVE NE
Practice Address - Street 2:BUILDING 21
Practice Address - City:REDMOND
Practice Address - State:WA
Practice Address - Zip Code:98052-6309
Practice Address - Country:US
Practice Address - Phone:425-216-0550
Practice Address - Fax:425-216-0552
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-26
Last Update Date:2012-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACH60261762111NX0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111NX0800XChiropractic ProvidersChiropractorOrthopedic