Provider Demographics
NPI:1639265259
Name:MUSTAFA, MOHAMMAD ASIM (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAMMAD
Middle Name:ASIM
Last Name:MUSTAFA
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 1:461 N. MULFORD ROAD
Mailing Address - Street 2:SUITE 12
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-5165
Mailing Address - Country:US
Mailing Address - Phone:815-398-1009
Mailing Address - Fax:
Practice Address - Street 1:461 N. MULFORD ROAD
Practice Address - Street 2:SUITE 12
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61107-5165
Practice Address - Country:US
Practice Address - Phone:815-398-1009
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL2080A0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent Medicine