Provider Demographics
NPI:1477061612
Name:GHULAM MUSTAFA LLC
Entity type:Organization
Organization Name:GHULAM MUSTAFA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:OSAF
Authorized Official - Middle Name:
Authorized Official - Last Name:AHMED
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:520-269-3473
Mailing Address - Street 1:6989 N STARLIGHT RIDGE PKWY
Mailing Address - Street 2:
Mailing Address - City:LAKESIDE
Mailing Address - State:AZ
Mailing Address - Zip Code:85929-5086
Mailing Address - Country:US
Mailing Address - Phone:520-269-3473
Mailing Address - Fax:
Practice Address - Street 1:2401 E HUNT DR
Practice Address - Street 2:
Practice Address - City:SHOW LOW
Practice Address - State:AZ
Practice Address - Zip Code:85901-7920
Practice Address - Country:US
Practice Address - Phone:928-537-5333
Practice Address - Fax:928-537-1762
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-22
Last Update Date:2018-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ29210207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ29210OtherMEDICAL LICENSE