Provider Demographics
NPI:1922448927
Name:MUSTIN, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MUSTIN
Suffix:
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:PO BOX 48
Mailing Address - Street 2:
Mailing Address - City:MEAD
Mailing Address - State:OK
Mailing Address - Zip Code:73449-0048
Mailing Address - Country:US
Mailing Address - Phone:580-745-9610
Mailing Address - Fax:580-745-9891
Practice Address - Street 1:2601 NORTH WEST EXPRESSWAY
Practice Address - Street 2:SUITE 101E
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73112-7272
Practice Address - Country:US
Practice Address - Phone:405-858-8656
Practice Address - Fax:405-879-2171
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-05
Last Update Date:2013-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200049040Medicaid
OK100708380Medicaid