Provider Demographics
NPI:1245545656
Name:MUSTAFA, MANZUR
Entity type:Individual
Prefix:
First Name:MANZUR
Middle Name:
Last Name:MUSTAFA
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 1:20270 MIDDLEBELT RD STE 4
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2000
Mailing Address - Country:US
Mailing Address - Phone:248-442-7500
Mailing Address - Fax:248-442-7590
Practice Address - Street 1:20270 MIDDLEBELT RD STE 4
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-2000
Practice Address - Country:US
Practice Address - Phone:248-442-7500
Practice Address - Fax:248-442-7590
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-10
Last Update Date:2010-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5501006945225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist