Provider Demographics
NPI:1942281662
Name:KEMAL, MUSTAPHA (MD)
Entity Type:Individual
Prefix:
First Name:MUSTAPHA
Middle Name:
Last Name:KEMAL
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 1:2 LORENZ INDUSTRIAL PKWY
Mailing Address - Street 2:
Mailing Address - City:LEDYARD
Mailing Address - State:CT
Mailing Address - Zip Code:06339-1946
Mailing Address - Country:US
Mailing Address - Phone:860-464-3045
Mailing Address - Fax:860-464-3043
Practice Address - Street 1:365 MONTAUK AVE
Practice Address - Street 2:L&M PHYSICIAN ASSOCIATION, INC.
Practice Address - City:NEW LONDON
Practice Address - State:CT
Practice Address - Zip Code:06320-4700
Practice Address - Country:US
Practice Address - Phone:860-442-0711
Practice Address - Fax:860-442-0262
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMD14994208100000X
CT035770208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1357706Medicaid
CT250000226Medicare PIN
CTD400090035Medicare PIN
CT1357706Medicaid
CT250000278Medicare PIN